American Association
FOB
Study and Prevention
Infant Mortality
TRANSACTIONS
OF THE
Fourth Annual Meeting
"Washington, D. C.
November, 14-17, 1913
PRESS or
FRANKLIN PRINTING
BAt-TIMORK
AMERICAN ASSOCIATION FOB STUDY AND PREVENTION OF
INFANT MORTALITY
Officers
1913 - 1913
President
Dr. L. Emmett Holt, New York
President-elect,
Dr. J. Whitridge Williams, Baltimore
First Vice-President Second Vice-President
Dr. Isaac A. Abt, Chicago Mr. Arthur D. Baldwin, Cleveland
Secretary Treasurer
Dr. Philip Van Ingen Mr. Anstin McLanahan
125 East 7lst Street, New York % Alex Brown & Sons, Baltimore
Directors
Terms Expire 1913
Dr. Wilmer R Batt, Harrisburg Dr. Joseph S. Neff, Philadelphia
Mr. Robert W. Bruere, New York Prof. M. Adelaide Nutting, Columbia
Dr. Hasbrouck DeLamater, Kansas City University, N. Y.
Dr. John S. Fulton, Baltimore Mr. Chas. A. Otis, Cleveland
Dr. Hastings H. Hart, New York Mrs. Wm. Lowell Putnam, Boston
Prof. C. R. Henderson, Chicago Dr. Herman Schwarz, New York
Miss Zoe La Forge, Detroit Dr. Lilian Welsh, Baltimore
Mr. Austin McLanahan, Baltimore Dr. Cressy L. Wilbur, Washington
Terms Expire 1914
Dr. H. B. Burns, Pittsburgh Dr. Caroline Hedger, Chicago
Dr. W. W. Butterworth, New Orleans Mr. Chas. Ford Langworthy, Washing-
Dr. W. H. Carmalt, New Haven ton
Dr. Charles V. Chapin, Providence Mr. Harold F. McCormick, Chicago
Dr. F. S. Churchill, Chicago Dr. Herbert C. Moffitt, San Francisco
Dr. J. F. B'dwards, Pittsburgh Dr. F. W. Schlutz, Minneapolis
Miss M. Frances Etchberger, Baltimore Dr. George M, Tuttle, St. Louis
Dr. C. E. Ford, Cleveland Dr. Wm. H. Welch, Baltimore
Terms Expire 1915
Miss Jane Addams, Chicago Dr. J. Morton Howell, Dayton
Miss Minnie H. Ahrens, Chicago Dr. James Lincoln Huntington, Boston
Mrs. W. N. Boyd, Atlanta Dr. Charles G. Jennings, Detroit
Dr, T. B. Cooley, Detroit Prof. Abby L. Marlatt, University of
Dr. Thomas Darlington, New York Wisconsin
Dr. W. A. Evans, Chicago Dr. H. T. Marshall, Univ. of Virginia
Prof. Irving Fisher, New Haven Dr. Helen C. Putnam, Providence
Mrs, A. E. Graupner, San Francisco Dr. J. Whitridge Williams, Baltimore
Terms Expire 1916
Dr. Isaac A. Abt, Chicago Mr. Sherman C. Kingsley, Chicago
Mr. Arthur D. Baldwin, Cleveland Miss Harriet L. Leete, Cleveland
Dr. Henry L. Coit, Newark Dr. E. B. Mumford, Indianapolis
Mr. Homer Folks, New York Dr. J. W. Schereschewsky, Washington
Dr. Henry F. Helmholz, Chicago Dr. J. P. Sedgwick, Minneapolis
Dr. L. Emmett Holt, New York Dr. Fritz B. Talbot, Boston
Dr. John Howland, Baltimore Prof. C.-E. A. Winslow, New York
Prof. H. E. Jordan, Univ. of Virginia
Terms Expire 1917
Mrs. S. S. Crockett, Nashville Dr. Langley Porter, San Francisco
Dr. H. J. Gerstenberger, Cleveland Dr. Thomas Morgan Rotch, Boston
Dr. S. McC. Hamill, Philadelphia Dr. H L. K. Shaw, Albany
Dr. J. H. Mason Knox, Jr., Baltimore Dr. Mary Sherwood, Baltimore
Dr. Linnaeus E. La Fetra, New York Mrs. Letchworth Smith, Louisville
Miss Julia C. Lathrop, Washington Dr. H. Merriman Steele, New Haven
Dr. H. M. McClanahan, Omaha Dr. Philip Van Ingen, New York
Dr. Charles Edward Ziegler, Pittsburgh
Executive Secretary
Miss Gertrude B. Knipp
Medical and Chirurgical Faculty Bldg.
Baltimore, Md.
COMMITTEES
1912 - 1913
Executive
Dr. L. Emmett Holt Dr. Helen C. Putnam
Dr. Henry L. Coit Dr. Mary Sherwood
Dr. Hasbrouek DeLamater Dr. Philip Van Ingen
Dr, John S. Fulton Dr. Cressy L. Wilbur
Dr, J. H. Mason Knox, Jr.
Prog-rani
Dr. Lilian Welsh Dr. Fritz B. Talbot
Dr. S. McC. Hamill Dr. H. J. Gerstenberger
Prof. C,-B. A. Winslow
Educational Leaflet and Booklet
Dr. H. J. Gerstenberger, Cleveland, Chairman
Eugenics
Prof. H. B. Jordan, University of Virginia, Chairman
and Social Work
Miss Harriet L. Leete, Cleveland, Chairman
Obstetrics
Dr. Mary Sherwood, Baltimore, Chairman
Pediatrics
Dr. Henry F. Helmholz, Chicago, Chairman
Public Scliool Education, for Prevention of Infant Mortality
Dr. Helen C. Putnam, Providence, Chairman
Vital and Social Statistics
Miss Julia C, Lathrop, Washington, D. C., Chairman
Finance
Dr. J. H. M. Knox, Jr., Baltimore, Chairman
Transactions
Dr. John S. Fulton, Baltimore, Chairman
Local Arrangements
Dr. Samuel S. Adams, Washington, D. C., Chairman
"WASHINGTON
Committee on Local Arrangements
Chairman, Dr. Samuel S. AdamsDr. Danl. O. Leech
Dr. Geo. N. Acker
Dr. John P. Anderson
Dr. Ed. A. Balloch
Dr. Marcus M. Benjamin
Dr. Francis B. Bishop
Surg. -General Eupert Blue
Dr. Win. Cline Borden
Dr. W. Sinclair Bowen
Dr. J. Wesley Bovee
Dr. Geo. W. Boyd
Dr. G. Marcus Brumbagh
Dr. Jos. H. Bryan
Dr. Wm. K. Butler
Dr. Julian M. Cabell
Dr. Bandolph B. Cannichael
Dr. DeWitt C. Chadwick
Dr. John Wm. Ohappell
Dr. Wm. E. Clark
Dr. John Thos. Cole
Dr. George W. Cook
Dr. K. C. Corley
Dr. S. Clifford Cox
Dr. Edgar P. Copeland
Dr. Henry J. Crosson
Dr. M. F. Cuthbert
Dr. J. B. G. Custis
Dr. Ira W. Dennison
Dr. Harry H. Donnally
Dr. Hugh C. Duffey
Dr. Johnson Eliot
Dr. Henry E. Elliott
Dr. Llewellin Eliot
Dr. Chas. H. Ferguson
Dr. Howard Fisher
Dr. Eaymond A. Fisher
Dr. Barnes A. Flynn
Dr. John A. Foote
Dr. Wm. Chas. Fowler
Dr. Walter A. Frankland
Dr. F. Fremont-Smith
Dr. W. J. French
Dr. Henry D. Fry
Dr. James A. Gannon
Dr. Fielding H. Garrison
Dr. L. W. Glazebrook
Dr. Lewis S. Greene
Dr. Chas. I. Griffith
Dr. Thos. A. Groover
Dr. Wm. C. Gwynn
Dr. B. L. Hardin
Dr. Harry T. Harding
Dr. Henry H. Hazen
Dr. Ida J. Heiberger
Dr. Daniel P. Hickling
Dr. Wm. Hite Hough
Dr. A. LeEoy Hunt
Dr. Virgil B. Jackson
Dr. Henry L. E. Johnson
Dr. L. B. T. Johnson
Dr. Louis A. Johnson
Dr. Lyman Fred. Kebler
Dr. Eichard Kingsman
Dr. James J. Kilroy
Dr. A. F. A. King
Dr. Jos. J. Kinyoun
Dr. Geo. Martin Kober
Dr. Chas. K. Koones
Dr. Danl. S. Lamb
Dr. Isabel H. Lamb
Dr. Frank Leech
Dr. Duff G. Lewis
Dr. Eobt. L. Lynch
Dr. James Geo. McKay
Dr. Dorsey M. McPherson
Dr. Henry C. Macatee
Dr. Francis S. Machen
Dr. G. Lloyd Magruder
Dr. Wm. L. Mallory
Dr. Wm. J. Manning
Dr. Collins Marshall
Dr. Wnou Cabell Moore
Dr. John F. Moran
Dr. Edwin Lee Morgan
Dr. Francis P. Morgan
Dr. W. G. Morgan
Dr. F. H. Morhart
Dr. Ed. E. Morse
Dr. Wm. K. Moulden
Dr. S. Brown Muncaster
Dr. A. L. Murray
I>r. Thos. E. Neill
Dr. Wm. S. Newell
Dr. John B. Nichols
Dr. John A. O'Donohue
Dr. Mary O'Malley
Dr. Saml. L. Owens
Dr. Henry P. Parker
Dr. Mary A. Parsons
Dr. Chas. A. Pfender
Dr. Henry A. Polkinhorn
Dr. L. H. Eeichelderfer
Dr. Emory W. Eeisinger
Dr. Chas. W. Eichardson
Dr. John L. Biggies
Dr. P. S. Eoy
Dr. G. M. Euffin
Dr. L. S. Savage
Dr. E. C. Schneider
Dr. J. W. Schereschewsky
Dr. E. G. Seibert
Dr. A. E. Shands
Dr. Danl. K. Shute
Dr. John C. Simpson
Dr. Edgar Snowden
Dr. Wm. F. Sowers
Dr. Francis A. St. Clair
Dr. Albert L. Stavely
Dr. J A. Stoutenburgh
Dr. L. B. Swormstedt
Dr. John A. Talbott
Dr. Louise Taylor-Jones
Dr. A. E. Thomas
Dr. J. L. Thompson
Dr. Millard Fillmore Thompg
Dr. E. W. Titus
Dr. Geo. T. Vaughan
Dr. J. Eussell Yerbrycke
Dr. E. E. Walker
Dr. J. Edgar Walsh
Dr. S. A. WatMns
Dr. E. W. Watkins
Dr. Newton E. Webb
Dr. W. A. WeUs
Dr. Chas. Wheatley
Maj. Eugene E. Whitmore
Dr. Oscar Wilkinson
Dr. Wm, Holland Wilmer
Dr. Geo. Wm. Wood
Dr. Eobt. S. Woodward
Dr. W. C. Woodward
Dr. Hamilton Wright
Dr. James C. Wynkoop
Dr. Fred. Yates
Mr. and Mrs. Ernest P. BickneH
Dr. and Mrs. J. C. Boyd
Mr. and Mrs. Whitman Cross
Mr. and Mrs. John J. Edson
Mr. and Mrs. Fred. Faust
Mr. and Mrs. T. M. Gale
Mr. and Mrs. W. T. Gill
Mr. and Mrs. Gilbert H.
Grosvenor
Mr. and Mrs. E, C. Heald
Mr. and Mrs. F. S. Hight
Dr. and Mrs. J. W. Kerr
Mr. and Mrs. G. A. King
Mr. and Mrs. Eobt, T. Lincoln.
Mr. and Mrs. C. L. Marlatt
Mr. and Mrs. J. N. McGill
Eev. Dr. and Mrs. Bandolph
McKim
Mr. and Mrs. H. S. Nyman
Mr. and Mrs. Albert M. Eead
Rev. Dr. and Mrs. Badchffe
Col. and Mrs. B. E. Bussell
Lt. Cdr. and Mrs. Leonard E.
Sargent
Mr. and Mrs. L. A. Simon
Mr. and Mrs. Herbert A. Smith
Surg.-General and Mrs. Charles
Stokes
Mr. and Mrs. William Waller
Justice and Mrs. Chas. White
Dr. and Mrs. Cressy L. Wilbur
Dr. and Mrs. Harvey W. Wiley
Mrs. Wna. Jennings Bryan
Mrs. Wm. Grinnell
Mrs. Jas. S. Harlaa
Mrs. John Hay
Mrs. Fairfax Harrison
Mrs. Christian Heuricb.
Mrs. Archibald Hopkins'
Mrs. D. F. Houston
Mrs. Gaillard Hunt
Mrs. Arthur Lee
Mrs. George Xavier McLanahan
Mrs. H. S. Nyman
Mrs. Welding D. Owen
Mrs. John D. Patten
Mrs. Henry A. Peckham
Mrs. Mai West
n Mrs. Horace Westcott
Mrs. Huntington Wilson
Miss Clara Bliss Pmley
Miss Mary Gwynn
Miss Constance D. Leupp
Miss Juliet C. Patton
Miss Catherine Saville
Miss Alene Solomons
Miss Florence P. Spofford
Miss Louise Stephenson
Miss Isabel Strong
Miss Julia D. Strong
Mr. Byron S. Adams
Mr. Jesse C. AdMns
Mr. E. W. Allen
Mr. Wm. H. Baldwin
Mr. J. H. Brickenstein
Mr. Henry P. Blair
Mr. W. Worthington Bowie
Mr. Roger S. G. Boutell
Mr. Aldis B. Browne
Mr. Arthur T. Brice
Mr. Walter A. Brown
Mr. N. London Burchell
Mr. D. J. Callahan
Mr. Wm. K. Carr
Mr. Wm. J. Carter
Mr. M. C. Chance
Mr. Wm. McK. Clayton
Mr. Philander R Clarton
Mr. G-. W. Coggeshall
Mr. A. B. Coolidge
Mr. Wm. K. Cooper
Mr. John F. Costello
Mr. Fred V. Coville
Mr. Wm. M. Davidson
Mr. Chas. Ray Dean
Mr. Wm. H. DeLacy
Mr. John Dolph
Mr. R. Golden Donaldson
Rev. A. J. Donlon
Mr. M. Dorset
Mr. Vernon W. Dorsey
Mr. Julian 0. Dowel!
Mr. Barton W. Evermann
Mr, Fred. A. Fenning
Mr. Lewis Flemer
Mr. Edmund K. Fox
Mr. Henry Gannett
Mr. Isaac Gans
Mr. Chris. J. Gockeler
Mr. Thos. Grant
Mr. Wm. F. Gude
Mr. G. W. Hanger
Rt. Rev. Alfred Harding
Mr. C, L, Harding
Mr. George E. Hebberd
Mr. Saml. B. Hege
Mr. Wm. B. Hibbs
Mr. Ralph W. Hills Mr.
Mr. H. L. Hodgius Rev.
Mr. W. D. Hoover Mr.
Mr. Walter Hough Mr.
Mr. L. 0. Howard Mr.
Mr. J. D. Hurd Mr.
Mr. T. B. Huyck Mr.
Mr. Thos. Hyde Mr.
Mr. Bernard T. Janney Mr.
Mr. Wm. Bruce King Rev.
Judge Martin A. Knapp Rev.
Mr. Charles A. Langley Mr.
Mr. Charles Ford LangworthyRev,
Mr. Wharton E. Lester
Mr. George W. Littlehales
Mr. J. Nota McGill
Mr. Le Roy Mark
Mr. Wm. A. Mearns
Mr. C. Hart Merriam
Mr. Lewis Menam
Mr. S. C. Neale
Mr. Clarence F. Norment
Mr. S. N. D. North
Mr. Henry T. Offterdmger
Mr. Myron M. Parker
Mr. Walter S. Penfield
Rev. G. F. Peter
Mr. Julius Peyser
Rev. Dr. U. G. B. Pierce
Mr. Gifford Pinchot
Mr. Walter S. Pratt, Jr.
Mr. Richard Rathburn
Mr. W. deC. Ravenel
Prof. E. K. Rawson
Mr. William F. Roberts
Rev. W. L. Russell
Mr. Miles M. Shand
Rev. Frank Sewall
Mr. Thomas W. Sidwell
Rabbi Abram Simon
Mr. W. W. Skinner
Mr. J. H. Small, Jr.
Rev. Dr. C. Ernest Smith
Mr.
Mr.
Mr.
Mr.
Rev.
Mr.
Mr.
Mr.
John Lewis Smith
, C. R. Stetson
H. C. C. Stile*
Joseph M. Stoddard
Joseph Strasburger
Chas. Trowbridge Tittman
A. C. True
F. N. True
Walter S. TTflord
, John Van Schaick, Jr.
, C. Rochford Stetson
Richard B. Watrous
, W. R. Wedderspoon
L. H. Wilder
George L. Wilson
Alexander Wolf
Simon Wolf
, Chas. Wood
James M. Woodward
S. Walter Woodward
Nathan C. Wyeth
Registration
Mrs. Louis A. Simon, Chairman
Sunday Session
Rev. Dr. John Van Schaick, Jr., Chairman
Publicity
Dr. H. L. B. Johnson, Chairman
Dr. Scott Breckenridge
Mr. John EL Tiedeman
Mr. Donald A. Craig
Mr. Hal H. Smith
Mr, W. R. Metcalf
Mr. F. G. Heaton
Mr. W. B. Bryan
Mr. B. A. Mattingly
Mr. Ray Barker
Mr. W. L. Ormerod
Mr. Perry Arnold
Mr. Raymond W. Pullman
Mr. Robert M. Gates
Dr. Theodore Merrill
Miss Gertrude B. Knipp
n. JL>. .DUJ.J-i.fi>, jr J.LUBUUJL &J-1 JL-'J. . v>,ivjjmjn3 o-i.cu.gcj., \_>j-i.Lv;<xgvs
W. W. Butterworth, New Orleans Mr. C. F. Langworthy, Washington
W. H. Carmalt, New Haven Mr. Harold F. McCormick, Chicago
Charles V. Chapin, Providence Dr. Herbert C. Moffitt, San Francisco
F. S. Churchill, Chicago Dr. F. W. Schlutz, Minneapolis
J. F. Edwards, Pittsburgh Dr. George M. Tuttle, St. Louis
AMERICAN ASSOCIATION FOB STUDY AND PREVENTION OF
INFANT MORTALITY
Officers
1913 - 1914
President
Dr. J. Whitridge Williams, Baltimore
President-elect
Mr, Homer Folks, New York
First V ice-President Second Vice-President
Dr. M. J. Rosenau, Boston Miss Julia C. Lathrop, Washington
Secretary Treasurer
Dr. Philip Van Ingen Mr. Austin McLanahan
125 Bast 71st Street, New York % Alex. Brown & Sons, Baltimore
Directors
Terms Expire 1914
Dr Samuel S. Adams, Washington Dr. C. E. Ford, Cleveland
Dr H. B^ Bjirns, Pittsburgh ^ ^ Dr. Caroline Hedger, Chicago
Dr
Dr
Dr
Dr
Miss^MfFrances'Etchberger, Baltimore Dr. Wm.~H. Welch, Baltimore
Terms Expire 1915
Miss Jane Addams, Chicago Dr. J. Morton Howell, Dayton
Miss Minnie H. Ahrens, Chicago Dr. James Lincoln Huntingdon, Boston
Dr. H. I. Bowditch, Boston Dr. Charles G. Jennings, Detroit
Mrs. W. N. Boyd, Atlanta Prof. Abby L. Marlatt, Univ. of Wis-
Dr. T. B. Cooley, Detroit consin
Dr. Thomas Darlington, New York Dr. H. T. Marshall, Univ. of Virginia
Dr. W. A. Evans, Chicago Dr. Helen C. Putnam, Providence
Prof. Irving Fisher, New Haven Dr. J. Whitridge Williams. Baltimore
Mrs. A. E. Graupner, San Francisco
Terms Expire 1916
Dr. Isaac A. Abt, Chicago Prof. H. E. Jordan, Univ. of Virginia
Mr. Arthur D. Baldwin, Cleveland Mr. Sherman C. Kingsley, Chicago
Dr. Henry L. Coit, Newark Miss Harriet L. Leete, Cleveland
Mr. Homer Folks, New York Dr. E. B. Mumford, Indianapolis
Miss M. S. Gardner, Providence Dr. J. W. Sehereschewsky, Washington
Dr. Henry F. Helmholz, Chicago Dr. J. P. Sedgwick, Minneapolis
Dr. L. Emmett Holt, New York Dr. Fritz B. Talbot, Boston
Dr. John Howland, Baltimore Prof. C.-E. A. Winslow, New York
Terms Expire 1917
Miss Ellen C. Babbitt, New York Dr. Langley Porter, San Francisco
Mrs. S. S. Crockett, Nashville Dr. Thomas Morgan Rotch, Boston
Dr. H. J. Gerstenberger, Cleveland Dr. H. L. K. Shaw, Albany
Dr. S. McC. Hamill, Philadelphia Dr. Mary Sherwood, Baltimore
Dr. J. H. Mason Knox, Jr., Baltimore Mrs. Letchworth Smith, Louisville
Dr. Linnaeus E. La Fetra, New York Dr. H. Merriman Steele, New Haven
Miss Julia C. Lathrop, Washington Dr. Philip Van Ingen, New York
Dr. ii. M. McClanahan, Omaha Dr, Charles Edward Ziegler, Pittsburgh
Terms Expire 1918
Dr. Wilmer R. Batt, Harrisburg Prof. M. Adelaide Nutting, Columbia
Dr. Gavin S. Fulton, Louisville University, N- Y.
Dr. John S. Fulton, Baltimore Mrs. Wm. Lowell Putnam, Boston
Dr. Hastings H. Hart, New York Dr. M. J. Rosenau, Boston
Prof. C. R. Henderson, Chicago Dr. Herman Schwarz, New York
Dr. John W. Kerr, Washington Dr, Lilian Welsh, Baltimore
Miss Zoe La Forge, Detroit Dr. Cressy L. Wilbur, Washington
Mr. Austin McLanahan, Baltimore Dr. William C. Woodward, Washington
Dr. Joseph S. Neff, Philadelphia
Executive Committee
Dr. J. Whitridge Williams Dr. L. Bmmett Holt Dr. J. H Mason Knox, Jr.
Dr. Philip Van Ingen Dr. John Howland Dr. Mary Sherwood
Miss M. S. Gardner Dr. J. L, Huntington Dr. Fritz B. Talbot
Program Committee
Dr S. McC. Hamill Dr. H. J. Gerstenberger
Prof. C.-E'. A. Winslow Miss Julia C. Lathrop
Dr. Fritz B. Talbot
Executive Secretary
Miss Gertrude B. Knipp
Medical and Chirurgical Faculty Bldg.
Baltimore, Md.
The fifth annual Meeting of the American Association
for Study and Prevention of Infant Mortality, will be held
in Boston, Mass., November 12-14, 1914.
TABLE OF CONTENTS
PAGE
List of Directors, 1912-1913. 5
List of Committees, 1912-1913 6
List of 'Directors, 1913-1914 9
Report of Meeting 15
Report of Executive Secretary 19
Report of Treasurer 23
Address of the President, L. Emmett Holt, M. D., LL. D.
Infant Mortality, Ancient and Modern: An Historical Sketch 24
Report on the English-Speaking Conference on Infant Mortality,
Henry L. Colt, M. D 55
Sessions :
Nursing and Social Work :
Report of the Committee, by the Secretary, Mrs. Frances
Freese Lichtenstein 59
Standards for Infant Welfare Nurses, Miss Zoe La Forge. 62
Discussion , 66
Private Duty Nurses and Their Work in Helping to Prevent
Infant Mortality, Miss M. Frances Etchberger 69
Discussion 71
Infant Mortality Nursing Problems in Rural Communities,
Miss Fannie F. Clement 75
Discussion 79
Pediatrics.
Statement by the Chairman, Henry F. Helmholz, M. D. . . 85
Simple Milk Dilution Feeding, Herman Schwarz, M. D. . . . 86
Discussion 89
Teaching of Hygiene and Its Relation to the Prevention
of Infant Mortality, I. A. Abt, M. D 91
Discussion 95
Heat and Infant Mortality, J. W. Scher eschew sky, M. D.. . 99
Discussion 128
Eugenics :
Statement by the Chairman, H. E. Jordan, Ph. D 133
Results from Experimental Breeding Bearing on the Prob-
lem of Infant Conservation (Abstract), Charles B.
Davenport, Ph. D 134
The Education of Parents in Practical Eugenics, Mrs.
John Hays Hammond 135
11
12 TABLE OF CONTENTS
PAGE
Discussion i 137
The Relation of Experimental Syphilis to Eugenics, Henry
J. Nichols, M. D 139
Discussion 146
Tuberculosis and Heredity, Harry T. Marshall, M. D 149
Discussion 156
The Education of Parents in Practical Eugenics, Evang-
eline W. Young, M. 'D 100
Discussion 164
National Puericulture, Antonio Vidal, M. D 169
Obstetrics :
Statement by the Chairman, Mary Sherwood, M. D 173
Prenatal Care, Henry Schwarz, M. D 174
Discussion 182
The Ideal Obstetric Out-Patient Clinic, Franklin S. Newell,
M. D 191
Discussion 200
Maternity Hospital Care for the Woman of Moderate
Means, George W. Kosmak, M. D 208
Reports :
New England Sub-Committee, J. Lincoln Huntington,
M. D., Secretary 218
New York and New Jersey Sub-Committee, George
W. KJosmak, M. D., Chairman 237
Sub-Committee for the Southeastern States and the
District of Columbia, John L. Norris, M. D., Chair-
man 246
Continuation Schools (Third Conference) :
Introduction by the Chairman, Helen C. Putnam, M. D 251
Report of Committee, by the Secretary, Abby L. Marlatt,
M. S 257
Discussion of Committee Report :
Miss Emma Suter Jacobs 269
Miss Alma Binzel 272
Discussion 277
General Session (Sunday) :
Infant Welfare and the Community, Mary Sherwood, M. D. 283
Address, W. C. Woodward, M. D 280
The Claim of the Baby, J. H. Mason Kin-ox, Jr., M. D 289
Session on Vital and Social Statistics :
Statement by the Acting Chairman, George M. Kober, M. D. 293
The Use of Vital Statistics for the Conservation of Infant
Life, W, C. Woodward, M. D 294
TABLE OF CONTENTS 18
PAGE
Discussion 303
Progress in Vital Statistics and Birth Registration, Cressy
L. Wilbur, M. D 313
Discussion 315
General Session (Monday) :
Part I. Reports of Local Activities:
Department of Health, Arthur L. Murray, M. 'D 320
The Instructive Visiting Nurse Society, Miss Isabel
Strong 326
The Woman's Clinic Auxiliary, Mrs. John Hays Ham-
mond 328
Providence Hospital, G. Lloyd Magruder, M. D 330
The Associated Charities, Miss Bell 331
Baby Hospital Camp, Louise Taylor-Jones, M. D 334
Women's Welfare Department of the National Civic
Federation, Mrs. Archibald Hopkins 335
The Infant Welfare Station of the Washington Diet
Kitchen Association, Miss Mary Gwynn 337
Monday Evening Club, Mr. Charles F. Nesbit , . 339
Central Milk Committee Neighborhood House, W. J.
French, M. D 339
Part II. Discussion of Ideal Plan:
The Department of Hlealth, C. E. Ford, M. D 341
The Relation of Baby Saving Activities to the Depart-
ment of Health and to Each Other, S. Josephine
Baker, M. D 351
The Ideal Visiting Nursing, Miss M. Adelaide Nutting . . .
The Maternity Hospital, J. Whitridge Williams, M. D . 355
The Hospital, L. Emmett Holt, M. D., LL. D 359
The Dispensary (Social Service Department), Dr. J.
H. Mason Knox, Jr 361
The Foundling Asylum and the Unmarried Mother,
Miss Ellen C. Babbitt 363
The Church, Rev. Dr. John Van Schaick, Jr 365
Affiliated Societies, Reports of 367
Membership List 420
Index , 439
FOURTH ANNUAL MEETING
of the
AMERICAN ASSOCIATION FOR STUDY AND PREVENTION OP
INFANT MORTALITY
The fourth annual meeting of the American Association for
Study and Prevention of Infant Mortality was held in Wash-
ington, D, 0., November 14 to 17, 1913, under the presidency of
Dr. L. Emmett Holt of New York City. The principal general
session took place at the New National Museum, and a popular
session arranged for Sunday afternoon was held at the Church
of Our Father ; all other sessions took place at the Hotel Wil-
lard. The schedule was as follows :
GENERAL SESSION
Friday evening, November 14, New National Museum. The
principal feature of this session was the presidential address of
Dr. L. Emmett Holt on "Infant Mortality, Ancient and Mod-
ern." The address was followed by an informal reception.
SECTION MEETINGS
Nursing and Social work. Miss Harriet L, Leete, Cleveland, Chairman.
Pediatrics. Dr. Henry F. Helmholz, Chicago, Chairman.
Eugenics. Prof. H, E. Jordan, University of Virginia, Chairman.
Obstetrics. Dr. Mary Sherwood. Baltimore, Chairman.
Continuation Schools of Home-Making. Dr. Helen C. Putnam, Provi-
dence, Chairman.
Vital and Social Statistics. Miss Julia C. Lathrop, Washington, Chair-
man ; Dr. George M. Kober, Washington, Acting Chairman.
POPULAR SESSIONS
Sunday afternoon at the Church of Our Father, Rev. Dr. John Van
Schaick, Jr., Chairman.
Monday afternoon at Hotel Willard. Reports on Local Activities. Dr.
Samuel S. Adams, Washington,
presiding.
Discussion on Ideal Plan. Rev. Dr. John Van Schaick, Jr., presiding.
MEETINGS OF THE BOARD OF DIRECTORS AND EXECUTIVE
COMMITTEE
The Board of Directors held two meetings, the first on Fri-
day morning, November 14, and the second on Saturday after-
noon, Nevember 15. The former was preceded by a meeting
14
FOURTH ANNUAL MEETING 15
of the Executive Committee. Beports presented at these meet-
ings included those of the Executive Secretary, the Treasurer,
and of the Chairman of the American Committee for the Eng-
lish Speaking Conference on the Prevention of Infant Mortal-
ity. Dr. H. J. Gerstenberger, Chairman of the Committee on
Educational Leaflet and Booklet, reported that the leaflet had
been copyrighted and published, and that the booklet was prac-
tically ready for publication.
The following committees were appointed by the President :
Nominations
Dr. S. M. Hamill, Chairman
Dr. J. H. M. Knox, Jr.
Dr. J. L. Huntington
Miss M. A. Nutting
Dr. Philip Van Ingen
Resolutions
Dr. J. W. Schereschewsky, Chairman
Dr. W. C. Woodward
Miss M. A. Nutting
Transactions
Dr. John S. Fulton, Chairman
The appointment of the following committees was authorized
by the Board of Directors :
Prenatal Work
Dr. J. Whitridge Williams, Baltimore, Chairman
Mrs. Wm. Lowell Putnam, Boston
Dr. Cressy L. Wilbur, Washington
Baby Health Contests
Dr. L. Emmett Holt, New York City, Chairman
Miss Ellen C. Babbitt, New York City
Dr. Philip Van Ingen, New York City
Traveling EsvhiUt
Dr. John S. Fulton, Baltimore, Chairman
Dr. Mary Sherwood, Baltimore
Dr. Lilian Welsh, Baltimore
BUSINESS MEETINGS OF THE ASSOCIATION
Business meetings of the Association were held Saturday
morning, November 15, and Monday afternoon, November 17.
A feature of the meeeting of Saturday morning was the pre-
sentation of brief verbal reports by representatives of the
16 AMERICAN ASSOCIATION
affiliated societies. The Executive Secretary reported that the
number of affiliated societies identified with the Association
was eighty-five; that written reports that would be published
in the Transactions had been received from forty-three, and
that thirty-five had sent delegates to the meeting.
This was followed by the annual election of directors. In
accordance with the amendment adopted at the Cleveland
meeting authorizing the enlargement of the Board of Directors,
the directorate was increased to eighty.
The following directors whose, terms had expired were re-
elected for a term of five years :
Dr. Wilmer R, Batt, Harristmrg Dr. Jos. S. Neff, Philadelphia
Dr. John S. Fulton, Baltimore Prof. M. Adelaide Nutting, New
Dr. Hastings H. Hart, New York York
Prof. C. B. Henderson, Chicago Mrs. Win. Lowell Putnam, Boston
Miss Zoe La Forge, Detroit Dr. Herman Schwarz, New York
Mr. Austin McLanahan, Balti- Dr. Lilian Welsh, Baltimore
more Dr. Cressy L. Wilbur, Washing-
ton
The following additional directors were elected for the terms
of years indicated :
FIVE YEARS
Dr. Wm. C. Woodward, Wash- Dr. M. J. Rosenau, Boston
ington Dr. John W. Kerr, Washington
Dr. Gavin S. Fulton, Louisville
FOUR YEARS
Miss Ellen C. Babbitt, New York
THREE YEARS
Miss M. S. Gardner, Providence, R. I.
TWO YEARS
Dr. H. I. Bowditch, Boston
ONE YEAR
Dr. S. S. Adams, Washington
At their meeting Saturday afternoon, November 15, the
Board of Directors elected
Mr. Homer Folks, New York City, President for 1914-1915.
At the same time the Board declared
Dr. J. Whitridge Williams, Baltimore, the President-elect, President
for 1913-1914.
FOR STUDY AND PREVENTION OF INFANT MORTALITY 17
The Board then elected the following other officers for 1913-
1914:
First Vice-President, Dr. M. J. Rosenau, Boston.
Second Vice-President, Miss Julia C. Lathrop, Washington.
Secretary, Dr. Philip Van Ingen, New York City.
Treasurer, Mr. Austin McLanahan, % Alex. Brown & Sons, Baltimore.
Executive Secretary, Miss Gertrude B. Knipp, Baltimore.
The Board of Directors elected the following Executive Com-
mittee :
Dr. J. Whitridge Williams Dr. John Howland
Dr. Philip Van Ingen Dr. J. L. Huntington
Miss M. S. Gardner Dr. J. H. Mason Knox, Jr.
Dr. L. Emmett Holt Dr. Mary Sherwood
Dr. Fritz B. Talbot
Program Committee:
Additional member, Miss Julia C. Lathrop, Washington, for a term
of five years.
The following resolutions were reported favorably by the
Committee and were unanimously adopted by the Association :
"Whereas, It is now well recognized that the services of nurses have
become an essential and indispensable part of nearly all forms of public
health work, the demand for them far exceeding the supply, and
"Whereas, It is the experience of public health organizations that in
many instances nurses so employed are found deficient in preliminary
training for public health work, especially in connection with infants
and young children.
Therefore, *be it resolved, That the American Association for Study
and Prevention of Infant Mortality urge training schools for nurses to
provide such instruction, both in theory and in practical training as
will enable nurses to render efficient service in public health work, and
Be it further resolved, By this Association that sanitary authorities,
visiting nurse and social service organizations be urged to place their
facilities for study and practical training, so far as is feasible, at the
disposal of training schools for student nurses and of graduate schools
for graduate nurses desiring to engage in public health work.
Resolved, That the American Association for Study and Prevention
of Infant Mortality reaffirm its previous resolution as to the desira-
bility of establishing a Federal Department of Health.
Whereas, The importance of further accurate scientific study of the
causes for the increase in infant mortality during hot weather is great,
18 AMERICAN ASSOCIATION
Therefore, le it resolved, That the American Association for Study
and Prevention of Infant Mortality hereby suggests to the United
States Public Health Service the desirability of making such studies
under the direction of that Service.
Whereas, Under the plans that have been worked out by the exposi-
tion management of the Panama-Pacific International Exposition, social
economy will be one of the central features of the exposition with
special emphasis on exhibits in hygiene;
Be it resolved, That the American Association for Study and Pre-
vention of Infant Mortality strongly urges the government exhibit
board to provide a comprehensive exhibit on hygiene, such exhibit to
include the problems of infant mortality.
Whereas, The Fourth Annual Meeting of the American Association
for Study and Prevention of Infant Mortality, at Washington, D. C.,
has been attended by signal success ;
Whereas, This success has been due in no small measure to the effec-
tive aid and organization of the local activities ;
Therefore, oe it resolved, That the hearty thanks of the Association
are due and are, hereby, extended
To the Committee on Local Arrangements, its chairman and its sub-
committees to wit:
The Committee on Registration
The Committee on Publicity
The Committee on Entertainment
The Committee on the Sunday Session
To the Local Press and the Press Associations for their good offices
To the Management of the Hotel Willard for courtesies extended.
Whereas, The American Association for Study and Prevention of In-
fant Mortality feels itself under special obligations to the faithfulness,
zeal and ability of its Executive Secretary, Miss Gertrude B. Knipp, for
the success which has attended its activities
Be it therefore resolved, That a special vote of thanks be and hereby
is rendered to Miss Knipp by the Association.
A resolution recommending the pasteurization of market
milk, was laid on the table. The following was adopted :
Resolved, That the entire matter be referred to a committee of five,
appointed by the president, to investigate and report at the next meeting
with respect to the use of raw, pasteurized, and boiled milk.
Dr. J. Whitridge Williams, the incoming president, was in-
troduced to the Association at the close of the session. An-
nouncement was made by the Secretary that the fifth annual
meeting would be held in Boston in the fall of 1914. He also
reported that the Washington meeting had been attended by
representatives from twenty-four States, the District of Colum-
bia, Canada, Argentine Republic, Italy and Scotland.
FOR STUDY AND PEEVENTION OP INFANT MORTALITY 19
REPORT OF THE EXECUTIVE SECRETARY
November 16, 1912 November 15, 1913
MEMBERSHIP
The Association closes its fourth year with a total paid-up
membership of 716.
FINANCES
The income from all sources has amounted to $6,579.82. The
balance on hand at the beginning of the year of $827.53 made
the total amount available for all purposes $7,407.35. The in-
come has been derived as follows: $3,987.74 from membership
dues; $1,545 from contributions; $284.50 from the sale of
Transactions. The itemized list is to be found in the Treas-
urer's Eeport.
A fund amounting to |653.85 has accrued from rentals for
the traveling exhibit. This rental was charged with the under-
standing that the money would be devoted to exhibition pur-
poses only, and that it would be reserved to cover the cost of
necessary repairs and to replace the exhibit as it becomes
worn out.
TRAVELING EXHIBIT
Through its traveling exhibit the Association has been able
to reach a much wider public this fourth year of its existence
than at any other time. The places at which the exhibit has
been shown have included :
At the opening of the New Educational Building, Albany, N. Y.
Tri-State Fair, Augusta, Ga.
Tri-State Fair, Columbus, Ga.
Board of Health, Jacksonville, Florida.
Child Welfare Exhibit, Providence, R. I.
Throughout the State of Wisconsin under the auspices of the Exten-
sion Division and Department of Home Economies of the Univer-
sity of Wisconsin.
Baltimore Babies' Milk Fund Association.
Minneapolis Infant Welfare Society
St. Paul Infant Welfare Society
Duluth Infant Welfare Department of the Scottish Rite Masons.
Lancaster, Pa. Department of Health.
Palmerton, Pa.
Chautauqua, Jacksonville, 111.
The State Fair, Grand Rapids.
Infant Welfare Society, New Orleans.
20 AMERICAN ASSOCIATION
The diversity of interests represented in the associations
under whose auspices the exhibit has been displayed is indi-
cative of the many sidedness of the welfare work with which
the crusade against infant mortality is identified.
AFFILIATED SOCIETIES
The number of affiliated societies on the paid-up list is 85,
and through them the Association is in touch with organized
activities in over 53 cities or towns in 27 states. Many of
these are in the larger cities, but there is a decided increase
in the societies that are coming in from the smaller communi-
ties. Some of the newer activities which appear in our list for
the first time are the Infant Welfare societies of Jacksonville,
Florida, New Orleans, Settlement Association of Houston, the
Infant Aid Association of Manchester, N. H., the Infant Wel-
fare Committee of the Associated Churches and Charities of
Syracuse. The scope and character of the work of the soci-
eties that are blazing the trail in infant welfare activities are
indicated in the reports that have been received within the
last few weeks from the affiliated organizations. These reports
have been asked for in accordance with the provision of the
Constitution regarding the relations of the affiliated societies
with the general organization. Fifty of the societies have re-
plied to the request for reports ; forty-three have sent reports
and thirty-five are sending official delegates to this meeting.
WORK AT THE; CENTRAL OFFICE
The work of the Association has been carried on along three
main lines: General propaganda, traveling exhibit and
through the work of standing or special committees.
The Executive Secretary has taken part, on invitation, in
the Maryland State Conference of Charities, the Alabama
Sociological Conference, the Annual Meeting of the Georgia
State Association of Graduate Nurses, a special meeting of
the Women's Civic Club of Cumberland and a number of local
meetings.
Activity in southern centers, notably in Georgia, In Florida,
in Alabama, Louisiana, in various cities in Texas, and educa-
tional campaigns carried on by the North Carolina State Board
of Health are among the straws that show where great oppor-
tunities exist at present. The work among the pioneer soci-
eties continues to be a source of inspiration to other com-
FOR STUDY AND PREVENTION OF INFANT MORTALITY 21
inunities; there is also much encouraging activity in the Mid-
dle West, and in every direction an enlightened interest in the
subject is being aroused.
THE ENGLISH CONFERENCE
At the request of the international organization, arrange-
ments for the participation of American activities in the
English Conference on Prevention of Infant Mortality, held in
London in August, 1913, were entrusted to our Association.
Dr. Coit was chairman of the American committee and Dr.
Van Ingen secretary.
THE CHILDREN'S BUREAU
The Association has been in close touch with the Federal
Children's Bureau, and there has been a frequent interchange
of material, reports, etc., with cordial cooperation along every
line.
CORRESPONDENCE
In connection with the educational propaganda and member-
ship campaigns carried on from the office, 18,660 pieces of mail
have been sent out, and over 50,000 pieces of printed matter
have been distributed. A summary of the clerical work
follows :
Total number pieces of mail sent out 18,660
Personal letters 3,095
Circular letters 5,919
Circularization (follow-up) 5,468
Postals 3,117
Receipts (sealed, but without letter) 444
Packages (mail) 617
AMERICAN ASSOCIATION FOR STUDY AND PREVENTION OF
INFANT MORTALITY
Paid Up Membership November 16, 191S, to November 15, 1913
Alabama 2
California 17
Colorado 3
Connecticut 18
District of Columbia 30
Florida 1
Georgia 4
Illinois 52
Indiana 5
Iowa 3
Kansas 1
Kentucky 7
Louisiana 6
Maine 3
Maryland 93
Massachusetts 46
Michigan 32
Minnesota 22
Mississippi 1
Missouri 17
Montana 1
Nebraska 2
New Hampshire 4
New Jersey 21
New York 104
North Carolina 3
Ohio 81
Oregon 4
Pennsylvania 77
Rhode Island 8
South Carolina 2
South Dakota 1
Tennessee 2
Texas 2
Utah 2
Vermont 2
Virginia S
Washington 3
West Virginia 1
Wisconsin 6
Philippine Islands 1
Hawaii 1
Canada 10
China 1
England 3
New Zealand , 2
Scotland . , 1
Total 716
Life members 15
Sustaining members 17
Contributing members 30
Affiliated societies 85
Active members 569
716
Respectfully submitted,
GERTRUDE B. KNIPP,,
Executive Secretary.
22
REPORT OF THE TREASURER
November 16, 1912, to November 15, 1913
23
Balance on hand November 16, 1912 :
General $629 18
Exhibition 192 36
Petty Cash 5 99 $827 53
Receipts :
Membership
Active $1,77574
Affiliated 455 00
Contributing and Sustaining 757 00
Life 1,000 00 $3,987 74
Contributions
General $213 00
fGuaranty 355 00
Committee on Obstetrics 25 00
Committee on Education 2 00
* Special Contribution, Babies' Dispensary
and Hospital, Cleveland 95000 1,54500
Exhibition (Rentals for use of Traveling Exhibit) 653 85
Transactions (Sale of printed copies) 284 50
Received from Journal of the American Medical
Assn. (For report of Cleveland meeting) 19 00
Refund by Georgia State Nurses' Assn. of travel-
ing expenses of Executive Secretary 39 56
Interest on bank balances 49 97
Sale of reprints 20 6,57!) 82
$7,407 35
Disbursements :
Salaries $2,600 00
Rent of Office 250 00
Furniture 75 40
Printing, General 818 68
Transactions of Cleveland Meeting
Printing 1,500 copies $90957
Distribution postage 8 04
expressage 77 16
wrapping 20 75
local delivery 6 70 1,022 22
Postage 373 24
Office Supplies 143 90
Clerical Help 383 45
Telephone 41 88
Exhibition (repairs and other expenses connected
with traveling exhibit) 239 97
Expressage and Telegrams 49 77
Multigraphing and Typewriting 60 30
Traveling Expenses 191 37
Miscellaneous (extra janitor service, water, ice, car
fare, clipping service, insurance on transac-
tions, etc 141 82 6,392 00
Balance on hand November 15, 1913 $1,015 35
General Fund $409 11
Exhibition Fund 606 24
Balance on hand November 15, 1913 $1,015 35
t Through the Finance Committee, in 1911, pledges amounting to $385.00 an-
nually for three or five years ($55 for 3 years and $330 for 5 years) were
received toward a Guaranty Fund. These were exclusive of the annual member-
ships.
* Completing payment of $2,586.21 pledged in 1911 toward cost of Cleveland
meeting, publication of Transactions and other expenses.
Respectfully submitted,
ATJSTIN MCIJANAHAN, Treasurer
American Association for Study ana Prevention of Infant Mortality,
Baltimore., Md.:
In compliance with the request of your Executive Committee, we have made
an audit of the accounts of the American Association for Study and Preven-
tion of Infant Mortality for the year ending November 15, 1913, and find them
correct, as stated above. Very truly yours,
Baltimore, Md., Feb. 2, 1914 AJLEX. BEOWN & SONS
INFANT MORTALITY, ANCIENT AND MODERN: AN HISTORICAL
SKETCH
* ADDRESS BY THE PRESIDENT
L. EMMETT HOLT, M. D., IJL. D., Professor of Diseases of
Children, Columbia University, New Yorls:
In considering what subject I might bring before you upon
an occasion like this, it has occurred to me that perhaps a
general review of the changed attitude of society toward in-
fants might prove not uninteresting a change so marked as
to seem almost revolutionary. I have tried to trace from the
earliest times the growth of the modern conception of the value
of infant life how it has come about, by what influences it
has been stimulated, and by what agencies the betterment of
conditions has been effected, with the hope that looking at our
work historically we may better appreciate the importance
of what has been done and see its significance in relation to
the future.
The problem of infant mortality is one of the great social
and economic problems of our day. No resources of the
State need so much to be conserved as do its children. A
nation may waste its forests, its water power, its mines and,
to some degree, even its land, but if it is to hold its own in its
struggle for supremacy its children must be conserved at any
cost. On the physical, intellectual and moral strength of the
children of today the future depends. In all training and
education physical considerations must come first. Unless
the infants are saved there will be no children to educate. It
is not true, as has sometimes been assumed, that a nation as a
whole is improved physically by a high infant death rate.
Visitors to the marasmus wards of a modern infants' hospital
often remark upon the uselessness or futility of saving these
infants. They look upon the effort as misguided philanthropy
and almost as a perversion of medical science, arguing that
however praiseworthy from a humanitarian point of view to
save such infant lives, it is false economy and does not im-
prove the race; that it interferes with the law of natural
selection, which is the survival of the fittest; that by efforts
to keep the feeble alive, degeneration of the race rather than
improvement in it is favored.
N< ^ Resented at the General Session, New National Museum, Friday night,
24
L. EMMETT HOLT, M. D. 25
The argument is not a strong one and is based upon
erroneous premises. In the first place, most of those who in
infancy are regarded as physically unfit were healthy at birth
and are merely the victims of a bad environment, improper
feeding and neglect conditions which it is quite possible to
remove. When these obstacles are overcome these infants not
only have the same chance to survive, but to grow into healthy,
even robust, children as have others. How many of the world's
brightest geniuses would have been lost had this law been
rigidly applied, who can say.* It is hard to tell who are the
unfit A high infant mortality results in a sacrifice of the
unjortun&te, not the unfit.
Again, many of the causes which produce infant deaths are
at the basis of delicate health and physical deterioration in
those who survive. Such children later may become a burden
to society. It is not enough to protect infants from early
death; it is equally important to remove so far as possible
those pernicious influences which have such an injurious effect
upon the child in the modern city and tend to make him so
greatly the physical inferior of the town or country dweller
of a half century ago. Excessive mortality among infants is
not a question which concerns the cities only nor the poor
alone. In matters of health the whole community stands
together, although the effects of unfavorable conditions always
fall most heavily upon the poor and upon the young.
A high infant mortality is in no sense a protection to our
body politic. We must eliminate the unfit by birth, not by
death. The race is to be most effectively improved by prevent-
ing marriage and reproduction by the unfit, among whom we
would class the diseased, the degenerate, the defective, and the
criminal. In working for the survival of the feeble and the
unfortunate we are not contravening nature's law and striv-
ing to save the unfit.
* "One Christmas day a premature posthumous son was born in England of
such an extremely diminutive size and apparently of so perishable a frame that
two women who were sent to Lady Pakenham, at North Witham, to bring some
medicine to strengthen him, did not expect to find him alive on their return. He
would have inevitably been consigned to the Caverns of Taygetus if the two
women had carried him to Spartan Tryers. As it was, the boy grew up Into
Newton, lived more than fourscore years, and revealed to mankind the laws of
the universe. If he had perished, England would not have been what she has in
the world. ... In Paris one evening a puny child in a neat basket was
picked up ; he had been left at the church door. The commissary of police was
about to carry him to a foundling hospital when a glazier's wife exclaimed, 'You
will kill him in your hospital. Give him to me, I have no children, I will take
care of him.' It was D'Alembert, who made innumerable physical discoveries."
William Farr.is
26 INFANT MORTALITY
POLITICAL AND ECONOMIC CONSIDERATIONS
We have been considering the question somewhat more
especially from its individual and sociological side. The polit-
ical or economic side is not less important. In several Euro-
pean countries the greatest argument for the protection of
infancy is to be found in a steadily falling birth-rate, so rapid
as to threaten the political position of the nation. Of twenty
European countries, nineteen have shown a declining birth-
rate between 1881 and 1905, the average decline being 3 per
1,000 of population. Only one state, Bulgaria, showed an
increase. 1 In nearly all there has been a steady decline, but
with great uniformity this has been more rapid since 1900.
The cause or causes of this general fall in the birth rate we
cannot here discuss ; but judging by the extent of this decline
they are certainly not accidental nor temporary.
In the United States our birth records are so imperfect that
definite conclusions cannot be drawn from them; but all evi-
dence goes to show that except among the immigrants the same
general decline exists as is seen in Europe. The problem of a
falling birth rate is not yet with us an economic one, but it
may perhaps at no distant day become so.
The situation has been recognized in France for a genera-
tion or more. Her statesmen have viewed with alarm the fact
that her birth rate was the lowest in Europe. She was among
the first, as we shall see later, to grasp the political significance
of this fact and to bestir herself to remove causes of a high
infant death rate. Germany, also, is now facing the question
of rapidly falling birth rate and realizes the imperative neces-
sity of meeting this by reducing the number of infant deaths.
THE SACRIFICE OF INFANT LIFE AMONG THE ANCIENTS
The infant problem is as old as the human race, although in
different places and at different periods of the world the view-
point has changed. Among the savages and barbarians the
question was one of getting rid of the superfluous children
when mouths became too many for the food supply to fill.
Later, among more advanced nations, the weak and feeble were
exposed to death because they were assumed to be of no value
to the State ; only those who were vigorous enough to grow up
into fighting men were deemed desirable citizens. In Sparta,
the State claimed a right over all children born. Every new-
born infant was passed upon by a committee, and upon their
approval the child was accepted ; upon their disapproval it was
L. EMMETT HOLT, M. D. 27
exposed to death. Those who were permitted to live were most
carefully reared, with the result that the Spartans became
physically the finest race of their time. 2 Lycurgus, Solon,
Aristotle, and Plato all regarded infanticide as proper and
desirable to prevent a too rapid increase in population, and
also to remove the weak and the deformed. 3 4 Only the Thebans
considered infanticide barbarous and made it a crime punish-
able by death. Exposure of weak children to death was not
frequent at Athens and in that city an establishment existed
in which a certain number of illegitimate children were reared
by the State.
In Eome the father had the power of life and death over his
newborn child. According to custom the infant was placed by
the midwife upon mother earth. If left upon the ground, it
was a sign that the infant was to be immediately exposed to
death; if the father desired to preserve its life, he indicated
this by raising the child in his arms and invoking the goddess
Levana. This act was known as "tollere infanterrv^ The idea
has come down to us in the expression "to raise a child." It is
also preserved in the French phrase, "elever un enfant."
In the early days of Eome the Greek practice was fol-
lowed of exposing to death delicate and deformed infants.
They were sometimes exposed in the market place, sometimes
at the foot of certain pillars, sometimes in the forests and
sometimes they were drowned. They were considered both
in Greece and Eome the property of any one who found them
and who chose to rear them. When no one claimed them they
were cared for by the State. When reared by private persons
they were often greatly abused, sometimes mutilated and used
for begging, and sometimes, it is said, "used for purposes of
magic."
Though maternal nursing was commonly practiced among
the Eomans many mothers in the higher ranks of society
neglected it, and Julius Csesar ridicules such women for
carrying little dogs in their arms instead of their own infants.
Tacitus, in complaining of Eoman degeneracy, says: "Form-
erly grave matrons attended to their own children as their
first family concern, but now they entrust them to some
Grecian girl or other inferior domestic." 5
At a later period the value of infant life began to be appre-
ciated. In the time of Trajan some organized assistance was
given to infants. Marcus Aurelius also showed an interest in
the foundling. Cicero states that Camillus, when Consul,
proposed a tax upon bachelors for the support of infants. 6
28 INFANT MORTALITY
In India and China infanticide was extensively practised
from the earliest time; indeed, with the exception of the He-
brews and Assyrians^ it was general among all the ancient
races. Though sometimes confined to girls, it usually was
extended to include also all delicate, feeble and deformed male
children. The motives everywhere were much the same
famine, poverty, or the promotion of national efficiency by
eliminating the weakling.
The attitude of society toward infant life was determined
largely by the relation of the child to the State. Its life was
considered of value if it was healthy, vigorous, and especially
if it was a boy ; but if feeble or deformed and, under certain
circumstances and in some countries, if a girl, it was exposed
to death without hesitation or regret. That mistakes in de-
ciding who were unfit were sometimes made is shown by the
fact that Cyrus, the son of Cambyses, was exposed in a forest,
but secretly saved by the woman who was sent to make way
with him. The right of infants to life and the value of infant
life as such was not recognized until very modern times. The
early idea of infanticide was bound up with the authority of
the father or the State over the life of the child. In India
and China, although infanticide is practised today, it has very
greatly diminished, and it does not meet with public approval.
INFLUENCE OF CHRISTIANITY AND THE EARLIEST PROVISION
FOR FOUNDLINGS
After the first few centuries of our era a different and more
humane attitude toward infant life is discernible. The first
evidence of legislation having for its object ''abandoned in-
fants" came with the establishment of Christianity in Kome.
Before that the authority of the parent was absolute. In the
beginning of the fourth century we find Constantine endeavor-
ing to prevent parents from abandoning their children and
giving aid to the needy from public funds; because, as he
said, "The wants of the newborn child must be filled without
delay/ 7 In the latter part of the fourth century the Em-
perors Valens and Gratian ordered that every parent should
bring up his own infants; they pronounced penalty against
exposing them and made infanticide punishable by death. In
530 Justinian gave liberty to foundlings and proposed that
they be educated at public expense, but long wars prevented
the carrying out of his plans. 4
There gradually grew up in the middle ages all over Europe
a general sentiment of pity for the foundling or the aban-
doned infant and this apparently was the chief motive which
L. EMMETT HOLT, M. D. 29
led to their reception in churches and hospitals, and later to
the establishment of special institutions for the protection
and care of these waifs of society. This was almost in-
variably done by the religious orders, seldom by municipal
or State authorities. All that was thought of in the begin-
ning was simply shelter for these unfortunates during their
usually brief existence.
In the sixth century at Treves a marble cradle was first
placed outside the door of the church to receive any infant
who might be placed there. 7 Later this example was fol-
lowed by many churches and afterwards by some public hos-
pitals. It is recorded 8 that at the end of the twelfth century
fishermen in the Tiber caught in their nets so many bodies
of newborn infants who had been drowned, that Pope Inno-
cent III. immediately arranged to have infants received in
the Hopital (Lit Saint-E ' sprit j this part of the hospital was
named "Conservaioire de la Routa."* In 1316 the Hospital des
Innocens was founded in Florence.
In the reign of Francis I., 3 toward the end of the fifteenth
century, we find a brotherhood formed to care for young in-
fants; and fifty years later the Hotel Dieu opened its wards
to receive any infants left at its door. These were placed in
wards with sick adults and, it is said, usually died in a few
days. Several private homes or shelters for their reception
were opened during that century, but until the end of the
seventeenth century no public foundling asylum existed in
France. 8 Not long after this, special institutions for found-
lings came into existence over the continent of Europe. Prac-
tically all these were under the aegis of the Church; shelter
and care for these children were furnished as a religions duty.
The Society of St. Vincent de Paul in 1638 seems to have
been the first to influence public authorities to acknowledge
the civil existence of foundlings. 8 A little later Louis XIV.
recognized the value to the State of these infants and grad-
ually the idea grew that the foundling not only had a right
to life, protection and care, but might be of value to the State.
The provisions for their needs were, however, very meagre
and wholly inadequate.
What the infant mortality was in the period of which we
have been speaking must be left to conjecture. No statistics
which are at all reliable are at hand. Both in public institu-
tions and out of them, the death rate must have been some-
thing appalling under conditions then existing.
* " The wretched mothers dropped their babies on the foundlings' wheel of
fortune (Ruota) instead of on the street." William Forr.is
30 INFANT MORTALITY
THE BEGINNING OF VITAL STATISTICS
A beginning of vital statistics in England was made in
1538 9 by Henry VIII., who ordered that the incumbent of
every parish keep a true and exact register of all christenings,
weddings and deaths. Although a similar order was issued
by Elizabeth in the next reign it was not until long after that
anything like complete records were kept. In the city of
Geneva, however, fairly full and complete vital statistics are
available since the year 1549. 10 But even in the most enlight-
ened countries as a whole little that is reliable can be obtained
in vital statistics until about a century ago, and in the ma-
jority of States for hardly half that time. In 1812 a law was
passed in England prescribing the form of registration for all
deaths and making one liable to a fine who did not comply. 11
However, "bills of mortality," as they were called, were kept
in many towns before that time, which enable us to form
some idea of infant mortality for an earlier period. Our own
country has been disgracefully behind most of the civilized
nations, and even now in only a few of our states are proper
records kept. Vital statistics are a form of national book-
keeping which is most essential if we would know what actual
conditions are. We in the United States have been most re-
miss in the matter of marriage and birth records. One of the
first tasks to which this Association has addressed itself is
to secure throughout the country complete figures of birth
registration. The importance of such records for a study of
the problem cannot be overestimated.
INFANT MORTALITY IN THE SEVENTEENTH AND
EIGHTEENTH CENTURIES
While we cannot know the infant death rate in percentages
in Europe in the seventeenth and eighteenth centuries, we
get some hints of what it was from certain facts in history.
Justin McCarthy, in his "History of the Four Georges," speak-
ing of Queen Anne, says that Anne had no children living
at the time of her death, 1714; she had borne her husband
a great many children, eighteen or nineteen, it is said, but
most of them died in infancy, and only one, the Duke of
Gloucester, reached his eleventh year. Granting that many
of them were probably delicate children, what a revelation
this is of the ignorance of the care and nutrition of infants.
If such a thing was possible in the royal family, what must
have been the conditions throughout the kingdom generally.
L. EMMETT HOLT, M. D. 31
Gibbon, the historian, born a generation later, in 1737, in
his "Memoirs" says: "I was succeeded by five brothers and
one sister, all of whom were snatched away in their infancy."
He continues, "The death of a newborn child before that of
its parents may seem an unnatural, but it is strictly a prob-
able, event, since of any given number born the greater num-
ber are extinguished before their ninth year. Without accus-
ing the profuse waste or imperfect workmanship of Mature
I shall only observe that this chance was multiplied against
my infant existence." He goes on to state that so feeble
was his constitution that in the baptism of each of his five
brothers his father's prudence successively repeated his
Christian name of Edward, that, in case of the death of the
eldest son, this name might still be perpetuated in the family.
Yet Edward Gibbon lived to the age of fifty-seven years, and
became one of the great men of his day.
In his time that a large proportion of infants born should
die was an accepted fact. It need not surprise us when we
consider the conditions of medical science at the time, the
dense ignorance regarding private and public hygiene and
sanitation, and the consequent ravages of infectious diseases.
The infant mortality in institutions was much greater than
elsewhere. In the Lying-in Hospital in Dublin from 1781 to
1785 it is said 12 that 16.5 per cent of infants born died before
they were two weeks old. By opening the windows and at-
tending to ventilation and cleanliness this was reduced to 4
per cent within a few years mainly by the elimination of
tetanus of the newborn, to which previously more than nine-
tenths of the deaths were due. In the British Lying-in Hos-
pital from 1750 to 1759 the mortality was 6% per cent of the
infants. 9 Percival, 13 writing in 1789, states that in Manches-
ter half the children born die before reaching the fifth year.
A writer in a French medical journal, 14 in 1780, makes the
statement that in that country half the children born died
before the end of the second year. At this time, the latter
half of the eighteenth century, we are warranted in stating
that the infant mortality generally was over one-fourth of the
total mortality, and the mortality under five years over half
the total mortality.
That the infant death rate was excessively high excited no
comment or surprise. This had always been the case; and it
was considered unfortunate but inevitable. Human life was
cheap, and infant life cheapest of all. Gradually the opinion
grew that this was not so inevitable and necessary as it
seemed. There appeared now and then in different parts of
32 INFANT MORTALITY
the world men who were impressed with the idea that much
of this sacrifice of infant life was unnecessary and might be
prevented. Some of these persons were philanthropists, but
most of them were physicians who foresaw the dawn of a
better day for the infant in the not distant future and recog-
nized some of the means through which this might be hastened.
The value of human life, and especially the intrinsic right of
the infant to a chance for life, gradually came to be recog-
nized during the nineteenth century. It seems to have been
one of the results of the growth of democracy, which spread
so rapidly after the French Eevolution.
Although the economic value of infant life and the im-
portance of saving the children were not yet appreciated, there
were even in this period voices of warning and protest raised
against the conditions then prevailing with reference to in-
fants. Black, 15 writing in 1782 an historical sketch of medi-
cine, states that in Great Britain during the latter half of
the seventeenth century there were only three men, one of
whom was the renowned Sydenham, who gave any special
attention to the diseases incident to young infants. He says :
"Up to this century the management of these tender creatures
in sickness was left to ignorant old nurses and rude quackery.
Even at present the bills of mortality, in cities especially, are
a melancholy proof that the carnage made among the young
part of the human species has not yet attracted the attention
of medical writers."
In 1749 William Cadogan, 16 of the London Foundling Hos-
pital, talks more hopefully. He says, "It is with great pleasure
I see at last the preservation of children become the care of
men of sense; the publick will soon find the good and great
effects of it. Children have been left too long to the super-
stitious care of old women. What is needed is a philosophic
knowledge of nature, to be acquired only by learned observa-
tion and experience." These and other contemporary writings
in the same strain give us glimpses of conditions which may
be regarded as fairly typical of the times.
CONDITIONS IN ENGLAND AT THE BEGINNING OF THE
NINETEENTH CENTURY
The early part of the nineteenth century witnessed a con-
siderable fall in infant mortality due to the introduction of
the practice of vaccination. To us at the present day that
small-pox was ever a large factor in infant mortality seems
surprising. Yet writers of that day tell us that small-pox
committed its chief ravages upon children under, or about,
L. EMMETT HOLT, M. D. 33
the age of two years; also, that one-fifth of all the children
born died of small-pox before reaching the tenth year, and
that one-third of all the deaths of children were due to this
cause. 17
An interesting picture of conditions existing in England in
the beginning of the nineteenth century is given by John
Bunnell Davis in a small book published in 1817, with the
following title: "A Cursory Inquiry into Some of the Prin-
cipal Causes of Mortality among Children, with a View to
Assist in Ameliorating the State of the Kising Generation in
Health, Morals and Happiness." 17 Davis is to be regarded as
a pioneer in this field. His work shows not only evidence of
careful study of the problem of infant mortality as presented
by the conditions existing at his day, but also a grasp of
principles to be applied in remedying the evils of the time.
We find him quite modern in his ideas, and many of the things
advocated by him are those upon which we of the present day
place the greatest emphasis. He strongly urges the import-
ance of maternal nursing and the moral obligation of it.
He says, "A practice more fatal in its effects than the com-
bined operation of all other causes is that of wet nursing and
the high mortality among wet nurses' infants." Again, "One
way for men to become good husbands and fathers is for
women to become real mothers." He saw that maternal nurs-
ing not only saved life, but was an important factor in the
future health of the child. "This practice [maternal nursing]
so loudly called for by nature renders children more robust,
and they are better able to resist a thousand causes of death
which threaten them in the arms of a stranger." "Is it," he
says, "too much to hope, to expect, indeed, that mothers will
see the necessity of this and will practice a virtue so noble, so
precious, and so natural." The economic importance of pre-
venting infant mortality did not escape him. "To promote
the health and vigor of its subjects is the primary object of a
nation's strength."
Davis laments the fact, which was very patent in his day,
"that from causes inexplicable the disorders of children do
not appear to have met with that exclusive and peculiar at-
tention which their obscure and fatal nature requires." Though
he met with much opposition and many discouragements, his
efforts resulted in what seems to have been the only public
dispensary for children in London in 1816.
Davis perceived the educational value and practical im-
portance of combining with the special work of his dispensary
for children social service by a voluntary corps of house visi-
34 INFANT MORTALITY
tors. He says : "If benevolent ladies could be prevailed upon
to form district committees to visit and inspect the health
of sick indigent children, much practical good would result
from a medical and moral point of view. By such visitations
as these it may be predicted that the instances of mortality
among children will be quickly diminished; at the same time
that such benevolent females corrected the absurd notions
and errors of the poor as to the domestic management of their
children." He also printed and circulated leaflets giving
rules for the care of children at home and directions for the
management of common ailments. Three methods of feeding
were in vogue in Davis's day maternal nursing, which was
of course the rule, though it appears not infrequently given
up voluntarily; wet nursing, the infant being usually taken
to board in the home of the wet nurse ; and artificial feeding,
or '"bringing the child up by hand. 77 The last-mentioned
method was almost invariably unsuccessful. The mortality
was appalling, comparatively few survived when so fed.
EFFECTS OF URBANIZATION OF POPULATION AND OF THE
FACTORY EMPLOYMENT OF WOMEN
The reduction of infant mortality following the introduction
of vaccination was only temporary, for two great influences
dependent upon the industrial development of the time came
into existence, both of which were most prejudicial to infant
life. These were the rapid growth of cities at the expense of
the country and the extensive employment of women in fac-
tories. The urbanization of the population of most European
countries has gone steadily forward with increasing rapidity
since the beginning of the nineteenth century. In America
it has been marked only since the Civil War.
City life a hundred or a hundred and fifty years ago, though
cities were small as compared with those of today, was not
safeguarded as it now is by modern sanitation, with its laws
of hygiene. The older cities were compactly built, with nar-
row streets, very inadequate provision for light and air ; and
very few parks or breathing places. Plumbing was unknown,
sewerage very rare, the water supply scanty and easily con-
taminated, and such preventive measures of disease as food
inspection, quarantine and disinfection in contagious dis-
eases, and proper street cleaning were still undreamed of.
The average city, with a population of 20,000 or 30,000 at the
beginning of the nineteenth century, exhibited unsanitary
L. EMMETT HOLT, M. D. 35
conditions and often an overcrowding which can be compared
only to the very worst districts in New York or London today.
When in snch surroundings, a mother relinquished the per-
sonal care of her infant to become a factory employed, and
when maternal nursing was replaced by substitute feeding
carried out by one densely ignorant of the first principles of
the subject, the results can well be imagined.
The relation to infant mortality of the employment of
women in industries away from their homes is a question of
real and fundamental importance. No single factor is so
prejudicial to infant life as taking the mother away from her
infant after the first month, often sooner than this, and keep-
ing her away at work for six days in the week, thus depriving
the child of the advantage of maternal nursing and substi-
tuting for the mother's care usually that of a young, ignorant,
inexperienced person, frequently only a child, often an invalid.
Factory work told even more upon the health of women then
than it does today. Work was harder, hours longer, wages
smaller and the factories frequently most unsanitary.
CONDITIONS IN EUROPE IN THE MIDDLE OP THE NINETEENTH
CENTURY
The conditions prevailing in Europe in the middle of the
nineteenth century are pretty fully set forth in the Journal of
the Statistical Society of London, in 1866. 18 At this time,
about 1860-61, the infant mortality per 1,000 of registered
births was as follows : Sweden, 141 ; Scotland, 149 ; England,
170; France, 223. In all of these countries the birth records
are fairly complete and the figures may be taken as indicating
comparative conditions in the different countries. The lower
mortality of Sweden and Scotland was attributed partly to
the cooler climate and partly to the more general practice of
maternal nursing and its continuance for a longer period.
Wide differences were seen in different towns and districts
of the same country, this varying very constantly with the
extent to which women were employed away from their homes,
whether in factories, in agriculture or other industries. In
one province in Finland, where the mortality was excessive,
investigation showed a great lack of maternal nursing. While
the mothers were away at work in the fields the infants were
fed, according to an ancient custom, upon sour milk from a
horn suspended over the cradle. This contrivance was evi-
36 INFANT MORTALITY
dently the prototype of the nursing bottles with long glass and
rubber tubes that were very generally employed with us until
twenty-five years ago. The state of the milk and the results
seem to have been much the same in both instances.
In France, the treatment of infants, especially in the coun-
try districts, is described as deplorable. A contemporary
writer 18 says : a The women work in the fields nearly as much
as the men, which affects feeding and all domestic arrange-
ments." The bad results and high infant mortality were at-
tributed largely to artificial feeding or bad wet nursing.
There was exceptionally little breast feeding and even when
ill, infants were still fed on insufficient cow's milk and pap ? or
bad soup and black bread. "The mothers cannot, or will not,
nurse their infants because they are obliged to go out to work."
The same writer concludes that it was common experience
for three-fourths of the infants fed in this manner to succumb
in a very short time.
In Norway, notwithstanding the poverty of the peasants,
the infant mortality was low. Because of their poverty, breast
feeding was almost universally practiced and frequently con-
tinued until children were two or three years old. That breast
feeding was found to be the cheapest by these people at this
time is suggested which may well be pondered by those seek-
ing a solution of the problem of infant mortality at the present
time.
In England the infant mortality bore a very close relation
to the extent to which women were employed in factories. An
interesting demonstration of this is seen in the cotton mill
district of Lancashire during our Civil War. During the first
year of the war the imports of cotton decreased 40 per cent
with the result that when the conditions at the mills were at
their worst there were in Lancashire alone 247,000 operatives
idle and 165,000 others working on part time. Of the entire
population of the district, 24 per cent were receiving charitable
relief. The effect of this was a marked increase in the general
mortality as a result of privation and poverty, but a surpris-
ing reduction in the infant mortality. In the year before the
war it had been 184 per 1,000 births; at the height of the de-
pression of the cotton industry it fell to 168, but rose again
after the close of the war, when work in the mills was fully
resumed, to 200 per IjOOO. 11
A somewhat similar thing was seen during the Siege of
Paris; 11 while the general mortality doubled, the infant mor-
tality fell 40 per cent. Opportunities for outside work being
L. EMMETT HOLT, M. D. 37
shut off, women could not go out to work and were compelled
to stay at home and so nursed their children.
An investigation was made between 1859 and 1861 into the
sanitary condition of England by Sir John Simon and others, 11
as a result of which the conclusion was reached that just in
proportion to the number of adult women employed in fac-
tories or agriculture the mortality of their infants increased;
that in districts where the proportion of women so employed
was large the infant mortality was from two to three times
as great as in the standard districts. The care, or, rather,
the neglect, of infants under such circumstances is described
as "almost murderous." Homes were ill kept, infants badly
fed or starved and the cries of hunger or distress quieted by
opiates, which were in great demand in centers of manufac-
turing industry. An operative of the better class in Birming-
ham, England, who collected money for expenses attendant
upon the death of children in a factory employing 150 women
gives it as his opinion that at this time 10 out of every 12
children born to the married women in this factory died within
a few months after birth.
An interesting and instructive comparison has been made
in England between the average mortality for ten years in
eight towns with extensive textile industries, and eight other
towns of approximately the same size. The average deaths
in the textile towns was 182 per 1,000 of births ; in the non-
textile towns it was 150. In the textile towns 43 per cent of
the married women were employed in industry; in the non-
textile towns but 3 per cent. 11 There seems thus to be a very
definite and intimate relation between the extent to which
women are employed in industry and the infant mortality
rate.
MILK PRODUCTION IN NEW YORK IN 1840
The situation in the cities of our own country in the middle
of the last century was little better than in those of Europe.
A graphic picture of the conditions prevailing at the time in
New York is given in "An Essay on Milk" by Eobert Hartley,
which was published in 1842. 15) At that date he states that
fully five-sixths of the milk consumed in New York was from
cows housed in the city and fed upon distillery waste. Ad-
joining a distillery at * Eighteenth Street and Ninth Avenue
were cattle sheds containing as many as 2,000 cows at one
time. The animals were kept under conditions which were
foul almost beyond description ; they had no exercise, no fresh
38 INFANT MORTALITY
air, no fresh food and no hay. Their sole food was the so-
called "distillery slop/ 7 of which they consumed barrels a day.
The stalls were rented to the owners of cows for five dollars
a year and the food was supplied at nine cents a barrel. The
milking was often done by city tramps, who performed this
labor for the privilege of sleeping in the cow sheds. Compare
for a moment these conditions with those existing in an up-
to-date dairy of the present, with its cement floors, white-
washed walls, sterile utensils and sterilized milking suits of
the trained men. It should be remembered that the conditions
alluded to were the rule, not the exception, and that for the
great majority of infants deprived of maternal nursing this
milk was their food; it was, in fact, the only milk obtainable.
Those who have read Paul Leicester Ford's book, "The
Honorable Peter Stirling," will recall that this ambitious
young attorney first came into notice as the prosecutor of
the milk dealers at the time of which we are speaking.
The mortality records of the time, imperfect though they
are, reflect the unwholesome conditions which we have
described.
With a population of a little more than 300,000, in 1840
New York had a death rate of 25 per 1,000, and one-fourth of
the deaths were in infants and over half were in children
under five years. The records of the time in Boston and
Philadelphia show about the same conditions prevailing there.
HIGH INFANT DEATH BATE OF THE LAST HALF OF
THE NINETEENTH CENTURY
Throughout the nineteenth century, especially the latter
half, to its very close, we note a constantly high infant mor-
tality. Although owing to advances in medicine, hygiene and
modern sanitation, general mortality records show a fairly
uniform decline after about 1870, there was no general fall
in infant mortality till 1900.* In many places there were seen
side by side a falling general mortality and a rising infant
mortality.
* Infant Mortality per 1,000 Births for Different European Countries for Five-
Year Periods.i
England
and Ire- Scot- Ger-
Wales land land France many Italy Belgium Norway Sweden
1881-'85 139 94 117 167 207 175 156 99 116
1886-'90 145 95 121 166 208 175 163 96 105
1891-'95 151 102 126 171 205 185 164 98 103
1896-'00 156 106 129 159 201 168 158 96 101
1901- J 05 138 98 120 139 190 168 148 81 92
L. EMMETT HOLT, M. D. 39
It is barely forty years, or only since 1870, that the new in-
terest in the lives of infants has been manifest This has come
about partly through a growth in humanitarian ideas regard-
ing the value of infant life, wMch has been accompanied by a
desire to ameliorate social conditions upon which a high infant
mortality depends. This was first felt by individuals, but
soon came to be appreciated by municipalities and finally by
states and nations. Together with the growth of the humani-
tarian idea has been the development of sanitary science and
preventive medicine and the great advances in our knowledge
of the diseases of children which have made it possible to
check, to some degree at least, the enormous infant death rate,
which had continued almost the same since vital statistics
were first kept.
EARLY ORGANIZATIONS TO SAVE INFANT LIFE
Some important organizations affecting child life, most of
them originating in France, had been in existence before 1870.
Perhaps the most valuable was the creche, or day-nursery.
The first one was founded in 1844 by Marbeau, mayor of the
first arrondissement of Paris, who, observing the neglect of
infants whose mothers were at work, and, finding that no pro-
vision for their care existed, conceived the idea of a place
where such a thing could be properly done. By the aid of
private subscriptions a room was secured in a poor street,
twelve willow cradles were installed and the whole placed in
charge of a nun, while a doctor visited the place daily. 20 It is
an interesting sidelight upon the care of infants of the time
to note that a part of the organization consisted of two persons
who were engaged as "rockers."
From this humble beginning the idea rapidly spread and
many more cr&ches were soon opened. Three years later the
Societe des Creches was formed to standardize methods of
work and facilitate cooperation. From France the creche
rapidly spread to Austria, Italy and Germany, and soon they
were opened all over Europe. Most of them received some
public support, but they depended largely also upon private
contributions. 20 They were usually in charge of nuns. While
the crdche has, perhaps, not been a large factor in reducing
infant mortality, it has done much in calling attention to the
neglect of infants of working women in cities and arousing
public interest in the welfare of infants generally.
40 INFANT MORTALITY
In 1865 a society was organized in France known as the
Societe Protectrice de VEnfance. 2 *- Its chief objects were to
encourage maternal nursing, watch over infants sent out to be
wet-nursed, and instruct mothers in all classes of society in
the care of their children. As a result of ten years' work this
society made a great impression on the infant mortality in
the district in which it operated.
France again led the way in 1876 in the organization of a
Society for Nursing Mothers (Societe d'Allaitement Mater-
nelle)^ This was destined to have a wide influence in the
reduction of infant mortality, for its example has been fol-
lowed and its methods imitated in many cities and countries
down to our own day. It approached the infant problem from
a different standpoint and sought to save the child by caring
for the mother. Before confinement, homes or refuges were
opened where poor and destitute women could be sheltered
for a few weeks until they were sent to maternity hospitals,
and assistance or partial support was given to nursing mothers
during the first year to make breast feeding possible. This
aid was supplemented by regular monthly observations of
these infants by physicians and visits by social workers. The
beneficial effects of this work were at once evident. In sixteen
years this society cared for 10,000 women in pre-confinement
homes, and Pinard says that no women received into maternity
hospitals from these homes died in childbirth, and that a
noteworthy improvement was seen in children born ; they were
above average weight and were much more vigorous than the
children of women not receiving such care. During the first
eighteen years of its existence the society aided nearly 40,000
mothers.
EARLY LEGISLATION
In 1872 there was passed in England what was known as
the Life Protection Act, 11 which was directed against the
crying evils resulting from the practice of farming-out infants.
It provided for the registration and licensing of all places
where infants apart from their parents were received for hire ;
to this a provision for inspection was subsequently added.
Two years later, in 1874, France passed a somewhat similar
law. 6 It was known as the Koussel Law, or Loi Protectrice
des Enfants. The custom prevailed extensively at that time of
sending young infants from the cities into the provinces to be
wet-nursed. Comby 6 states that the infant mortality under
these conditions was appalling. About 20,000 infants were
L. EMMETT HOLT, M. D. 41
sent from Paris in a single year, and the death rate among
them was 75 per cent. In some places it was even higher than
this. The death rate among the infants of wet nurses was
also enormous. The Koussel law aimed at the correction of
abuses which had grown up in connection with this wet-
nursing industry and provided for government inspection of
all places where infants under two years were cared for. The
passage of these two statutes is noteworthy as being the first
public recognition of the problem of infant mortality and the
first legal efforts made to diminish it.
The factory employment of mothers was early recognized,
and, as has already been mentioned, was an important cause
of a high infant mortality. 22 The next legislation relating to
this subject was the passage of laws which forbade the em-
ployment of women in factories for a certain number of weeks
before and after confinement.* Such a law was first passed
in Switzerland in 1877.
This example was followed by Hungary in 1884, and shortly
after this time in turn by Austria, Holland, Belgium, England
and Germany. 10 These laws varied somewhat in stringency.,
but all aimed to secure for the mother for a certain number of
weeks, usually for six after her confinement, and in some cases
for two weeks before, a certain immunity from labor of this
kind.
It has rarely happened that much has been accomplished
by legislation in reforming social evils and this has been no
exception. But it was another step forward. Where em-
ployers voluntarily continued wages during this period of
* European Laws Relating to the Employment of Women in Factories.io
Switzerland 1877 8 weeks, of which at least 6 after birth of child.
1897 Law amended requiring a longer rest before confinement and
special regulations regarding certain occupations.
Hungary 1884 4 weeks after confinement ; aided by insurance.
Austria 1885 4 weeks after confinement ; medical aid and a daily subsidy
equal to 60 per cent of the earnings of the working
woman.
Holland 1889 4 weeks after confinement.
Belgium 1889 4 weeks after confinement.
England 1891 4 weeks after confinement.
Germany 1891 4 weeks after confinement if medical certificate is shown ;
otherwise 6 weeks. Compulsory sickness insurance giv-
ing aid 4 weeks after confinement
Portugal 1891 4 weeks after confinement.
Norway 1892 4 weeks after confinement if medical certificate is furnished,
otherwise 6 weeks.
Women must not engage in dangerous, unhealthful or ex-
hausting trades during pregnancy.
Spain 1900 3 weeks after confimnent ; employer to pay wages.
Sweden 1901 4 weeks after confinement; less if a medical certificate is
produced.
Denmark 1901 4 weeks after confinement; less if a medical certificate is
produced.
42 INFANT MORTALITY
enforced cessation from work, as a certain number did, its
beneficial results were very striking. In other cases the opera-
tion of the law often was only to substitute for the previous
work in the factory harder work at the home. The main
benefit of these statutes was perhaps to arouse public opinion
by calling attention to the disastrous effects of hard work
under such circumstances both upon the health of mothers
and their infants, and to lead to efforts to ameliorate these
conditions by assistance in other ways. The enlightened em-
ployer of today recognizes the fact that efficiency of labor is
promoted by securing to employees good sanitary conditions
for work; but a generation ago this was hardly thought of,
much less practiced.
EECOGNIZED AS A SOCIAL PROBLEM
Interest in infant mortality as a social problem was, I
think, first shown at the Dublin meeting of the National
Society for the Promotion of Social Science in 1861. At this
session William Moore 12 made an address upon the causes of
excessive infant mortality in which he forcibly set forth the
conditions then prevailing in Great Britain and emphasized
the vital importance of this subject in its social and economic
aspects.
Ten years later in 1871, at a meeting of the Social Science
Association in Philadelphia, 23 the subject of infant mortality
was a topic of discussion. Attention here also was called to
the national importance of the welfare of the infants who
are, or should be made, a source of wealth to the state.
At the first meeting of the International Congress of Hygi-
ene, held in Brussels in 1876, 21 the subject of infant mortality
was considered. One of the great causes there assigned for a
high infant death rate was popular ignorance of the laws of
hygiene, and a strong plea was made for the more thorough
instruction not only of parents, but of young doctors and mid-
wives in this subject At the second meeting of this Con-
gress, held in Paris, in 1878, the hygiene of infancy was the
first topic for discussion. At this session a committee (con-
sisting of Bertillon, Marjolin and Bergeron) appointed to
make an investigation made a strong presentation of the sub-
ject of infant mortality, its causes, extent and remedies. This
drew forth a full discussion and excited great public interest.
Since that time, but especially since 1890, nearly every
congress of hygiene or social science has discussed the pro-
blem of infant mortality. I will mention only a few of the
L. EMMETT HOLT, M. D. 43
more important organizations and meetings for considering
this question: The National Congress for Infancy at Flor-
ence in 1896; the League against Infant Mortality, Paris, in
1902; the International Congress of Milk Depots, in Paris,
in 1905; the National Conference on Infant Mortality, in
London, in 1906; the International Union for the Protection
of Child Life, in Brussels, in 1907; a large exhibit in Berlin
in 1908, portraying the problem of infant mortality in all its
phases; a second National Conference on Infant Mortal-
ity, in London, in 1908; the German Society for the Pro-
tection of Infants, in Munich, in 1909 ; the American Associa-
tion for Study and Prevention of Infant Mortality organized
at New Haven in 1909; the Third International Congress for
the Protection of Infant Life in Berlin, in 1911; the English-
Speaking Conference on Infant Mortality, in London, in 1913.
These organizations and meetings are evidence of the world-
wide interest in the problem of infant mortality, and also give
an idea of how very recent all this interest is. Public con-
cern regarding this question is only about thirty years old
and the real awakening has come since the beginning of this
century.
CAUSES OF THE MODERN AWAKENING
In seeking for the causes of this awakening many factors
must be considered. It has not come about from any one in-
fluence, but is a result of many; the motives which have aided
in bringing this about have been varied. Some have been
stronger in certain countries, while in other lands different in-
fluences have been at work. Speaking generally for the world
at large, the humanitarian motive has probably been the
strongest one. It is the general desire for a betterment of
social conditions which has been most widely influential. This,
I think, has been the chief motive in America.
Among the European nations, especially France, it is the
economic aspect of infant mortality which has been upper-
most. It is surely not an accident that the French have
been foremost in their interest in this question and that so
many of the organizations or agencies for the reduction of
infant mortality have originated with them. For more than
two generations they have viewed with apprehension the fact
that with a high infant death rate their birth rate was the
lowest in Europe and steadily falling. (It has been from
20 to 22 per 1,000 of population for the past ten or fifteen
years ; it was 19.7, the lowest then recorded, in 1910.) How to
4:4 INFANT MORTALITY
save their infants has become a public question of the first
importance. With a smaller loss by emigration than either
Germany or England, the population of France in the twenty
years from 1891 to 1910 has increased less than a million,
while during the same period Germany has increased over
fourteen millions and England over seven millions. At the
present time the figures giving the birth rate are published
quarterly in the general press and the returns are scanned
with as much interest by publicists as the yield of wheat or
the factory output. It is not then surprising that a govern-
ment decree was issued only last year by the Minister of Fi-
nance for the formation of a large and influential Commission
to study this question.
Germany also has been greatly stirred by the economic
aspect of infant mortality. While her birth rate has been
and still is considerably higher than that of France, its fall,
especially in the past ten years has been more rapid. From
1890 to 1892 the average birth rate was about 35.5 per 1,000,
but it declined steadily, especially since 1902, to 31.1 per 1,000
in 1909. In five of the largest German cities the decline in
the birth rate from 1901 to 1910 has been from 33.5 to 24.1
per 1,000.
A third influence has been the progress made in medicine
and sanitary science and especially the enormous advances in
preventive medicine in the last thirty years, by which it has
been shown what was possible in hygiene and public health.
Better sewerage, pure water, clean milk, cleaner streets, food
inspection, attention t6 ventilation and to all matters of gen-
eral hygiene, have done much to overcome the unfavorable
effects of city life upon the very young. There has grown
up a certain noble rivalry among the health departments of
our greater municipalities in lowering the general mortality
rate, and especially the infant mortality, as being one of the
largest factors. This ambition to lower all previous records
is characteristically American, but it has brought about re-
sults which are truly remarkable and which make all previous
accomplishments in this direction seem like the work of
amateurs.
THE MILK DEPOT AND INFANT CONSULTATION AS INFLUENCES
Let us now pass to a consideration of some of the means
employed to bring about results of such magnitude. I have
already mentioned the French Society for Maternal Nursing,
which since 1876 emphasized what is now known as pre-
L. BMMETT HOLT, M. D. 45
natal care of the infant, and also the continuous observation
of young infants by trained visitors. Two other important
organizations, both French, came into existence in 1892 and
1894, respectively. These were the Consultations for Nurs-
lings (Consultations de Nourissons) and the Milk Depot, or
G-outte de Lait. 2 *
The first Consultation was organized by Budin in Paris in
connection with a maternity hospital. After discharge, the
infants were brought back for regular weighings and observa-
tion and examination for a period of two years; the mothers
instructed in infant hygiene and feeding and advised in minor
ailments. Breast feeding was encouraged and assisted; when
it was not possible, sterilized milk in separate feeding bottles
was supplied. The great advantage secured by this plan was
continuous, intelligent supervision of the mother and, through
the mother, of the infant from its birth.
Two years later, in 1894, the first milk depot was established
by Dufour. Its purpose was proper artificial feeding under
medical supervision. These two organizations, the Consulta-
tion and the Milk Depot, have since in many places been
merged into one. They may be considered as really marking
the beginning of the modern movement for the reduction of
infant mortality. They have spread all over the civilized
world and have proved to be, when properly conducted, one
of the most effective agencies, if not the most effective agency,
known for the reduction of infant mortality.
Several things are essential to the successful operation of
a milk depot. Budin has well said that the Consultation is
worth just as much as the physician who conducts it, but no
more. This work must be done by physicians, not trained
nurses nor social workers. The physicians must themselves
be properly trained for their task, and, finally, they must be
paid for it. The best results cannot be obtained by placing
this responsibility upon voluntary workers. The milk depot,
unless properly conducted, may, by increasing the facilities
for artificial feeding, tend to discourage maternal nursing,
with a final result, possibly, of increasing infant mortality.
While the distribution of clean, pure milk is important, it
should be realized that the instruction of the mother and
continuous observation of the child play a vastly larger part
Everything possible should be done to encourage breast feed-
ing and to aid it. The inexperienced mother is thus guided
not by the advice of ignorant and superstitious relatives or
friends, but by an intelligent and experienced person, who
not only tells her what to do, but shows her how to do it.
46 INFANT MORTALITY
The expense of conducting milk depots and consultations
upon a large scale is so great that private philanthropy can-
not be expected to bear it. They should be supported by the
municipality. In this way standardization of methods, proper
supervision and cooperation may all be secured.
OPERATION OF THE MILK DEPOT AND CONSULTATION IN VARIOUS
COUNTRIES
The milk stations and infant consultations are operated
somewhat differently in different places. In New York the
station is in charge of a paid physician and has in summer
two nurses and in winter one in attendance. Milk is distri-
buted practically at cost and if the mother is too poor to pay,
it is supplied by one of the relief agencies. The nurse visits
the mother in the home and teaches her the method of milk
modification. Consultations are held in most stations twice
a week. One of the chief difficulties is to secure attendance
of nursing mothers. Attendance of others is secured by the
distribution of milk. During the past three years the needs
of New York have been pretty well covered by milk stations.
There were 79 in operation during 1911, and 77 since that
time. These are open winter and summer. For the past two
years about two-thirds of these have been operated by the
Department of Health of the city, the remainder by private
agencies.
In Paris, 25 also, the city is districted and the attendance is
general. The infant consultations are often operated in con-
junction with, or located in, the maternity hospitals, so that
the work of the two is kept closely associated. A weekly
stipend of a few francs is given to mothers to enable them
to nurse their infants. This aids much in securing regular
attendance. In addition to the milk depot and the consulta-
tion there exists in Paris what is known as "the canteen/'
which is a restaurant where any nursing mother can obtain a
good meal for a nominal sum, or gratis if too poor to pay.
The milk depot and consultation are widely found throughout
the cities and smaller towns in France and about them cen-
ter the activities for the reduction of infant mortality. Wher-
ever they exist a marked reduction in the infant death rate
has occurred. In some cities in France pensions are given
by the municipalities to widows or other mothers with nursing
infants, where the family is dependent upon the mother's wages,
to enable them to remain at home and continue nursing.
L. EMMETT HOLT, M. D. 47
Germany 25 lias taken its ideas of methods for reducing infant
mortality and the care of infants and mothers largely from
France and with the German genius for administration they
appear to obtain better results, because the municipal authori-
ties seem to have a stronger hold upon the public. The
German campaign has been especially effective in dealing
with the problem of illegitimate infants. The size of this
class is so large and the death rate among them has been in
the past so high that in attacking the problem of infant mor-
tality this has been a subject of primary consideration. In
Berlin today the work for the reduction of infant mortality
is managed partly by the municipality and partly by private
beneficence, the two working in close cooperation. The chan-
nel of influence is chiefly the infant consultation, which is in
charge of physicians and nurses. They are less numerous than
in New York, there being last summer only seven of these in
Berlin, distributed through the poorer districts of the city.
Attendance is secured primarily from the birth registration;
nurses visit the homes of the poor and invite married women
to come to the consultations and bring their infants.
In the case of illegitimate children attendance is made com-
pulsory by the city authorities, just as in New York is attend-
ance upon the public school, and a truant officer is sent after
the mother if she does not report regularly. A small weekly
stipend is given which is deemed sufficient to supplement the
family income to enable the mother to nurse her baby; the
usual allowance is from one to four marks a week. This pay-
ment is in itself a very strong motive for regular attendance.
When the baby is no longer nursed the stipend is reduced or
withheld. Milk for artificial feeding is furnished at cost to
those who are unable to pay for the same. Mothers with ille-
gitimate children have different colored tickets from others
who attend the consultation, so that they are readily distin-
guished by the physicians and attendants. And all the rules
are much more stringently enforced in their case than with
the other group of patients.
In Leipsic 26 the illegitimate child becomes at birth a ward
of the municipality. From time to time its condition is in-
spected by public officers. It can be put out to nurse only
with persons publicly authorized. It must be produced
monthly at the municipal offices and examined. The result
is that the death rate of illegitimate infants in Leipsic is just
half that of other infants.
48 INFANT MORTALITY
In England 27 the milk depot lias not been very popular or
successful. The expense attending the distribution of good
milk has stood in the way of its extensive use, and dried milk
or infant foods have in many places been substituted. The
consultations, however, have attained much influence. To
secure attendance a cup of tea is sometimes provided for the
mothers at the consultations. This is regarded by them as a
sufficient inducement and takes the place of the pecuniary
reward which appeals so strongly to the thrifty German and
French matron. If in England the measures referred to have
been much less successful than in other countries, we must
remember that in that country the care and feeding of the
infant is generally believed to be the special province of the
nurse. The physician is frequently not consulted at all. The
effect of this is seen in the undue prominence given to nurses
and social visitors in the work of the milk stations and the
consultations, something greatly deprecated by the English
physician.
As an instance of what can be done in a single community
by stimulating public interest and a special incentive, the ex-
perience of Huddersfield, England, may be cited. In 1904 Mr.
Broadbent, when elected Mayor, announced he would give a
prize of one pound to the mother of every child born during
his term of office who presented it living and well at the end
of a year. A committee of ladies was formed to advise and
visit the mothers. The death rate of infants in that district
fell from 134 to 54 per 1,000. 26
ORGANIZED VISITATION OF MOTHERS OF NEWBORN INFANTS
Another important means for the reduction of infant mor-
tality is by visits by trained nurses to the home of every poor
mother of a newborn babe. This was first done extensively by
England. A statute known as "The Notification of Births
Act" 27 was passed in 1907, making the registration of births
within thirty-six hours compulsory. The old law allowed six
weeks in which to make such returns. As soon as a birth was
reported a visitor was sent to the home of every poor mother.
If proper advice and assistance were needed visits were re-
peated. The infants were by these means brought to the con-
sultations; when sick, they were visited by physicians. This
plan has been extensively followed in London and many other
large English cities, everywhere with striking results.
L. EMMETT HOLT, M. D. 49
METHODS FOLLOWED IN NEW YORK CITY
In New York the Health Department has a special corps of
191 28 nurses detailed for this work during the summer months.
Immediately upon receipt of a birth notice, which must be
filed within ten days, one of the nurses is sent to every tene-
ment house home. Subsequent visits are made at the request
of the mother, the midwife or the physician, if one is in at-
tendance.' These visits are usually welcomed and the early
advice much appreciated, especially by young mothers. Each
nurse has about 150 infants under her care and visits are
made every ten days; oftener, if they are ill. Breast feeding
is encouraged and assisted. It is estimated that the city has
not less than 50,000 ignorant mothers. This use of the birth
records is to be contrasted with a use formerly made of them,
where they could be obtained by the manufacturers of pro-
prietary infant foods who used the information as a guide in
distributing their circulars and samples.
While mothers are away at work the care of the baby so
often devolves upon the older children of the family that Dr.
Josephine Baker, Director of the Division of Child Hygiene
of the New York Health Department, has organized among
girls from twelve to fourteen years in the public schools a
"League of Little Mothers." Its object is the teaching, during
the summer months, of the principles of infant feeding and
hygiene. This was founded in 1911. In different seasons it
has had from 171 to 239 centers and an enrolled membership
which has varied between 15,000 and 20,000. 28 They have
weekly meetings, talks are given by physicians and nurses,
and examinations are held and medals awarded at the end of
the season to the members of each league who have been suc-
cessful in applying their knowledge. The amount of interest
awakened by this organization in the care of infants has been
remarkable. The girls learn easily and are most eager to put
their ideas in practice. What this will mean when a dozen
years hence these girls become mothers, who dare prophesy!
This movement has in it possibilities for betterment in the
future which are almost without limit.
Nowhere in the world does the problem of infant mortality
present greater inherent difficulties than in New York, from
the heterogeneous character of the population and an over-
crowding which in certain districts is not equalled in any
city in the world. European capitals London, Paris and
Berlin really know very little about the severe intestinal
50 INFANT MORTALITY
diseases which carry off infants in such numbers in New York,
Philadelphia and our other large cities. What has been
accomplished in New York is so conspicuous that the methods
followed may well be taken as a guide to other cities and may
be described in some detail.
Up to the year 1902 the work was somewhat desultory; the
Department of Health had confined its efforts to the three
summer months, the chief thing done being the employment
of a special corps of physicians to visit sick infants in the
tenements. That year the work was greatly enlarged and
visiting nurses were employed to follow up cases. Inspection
of milk on a considerable scale was begun. During the next
six years more and more private organizations came into the
field aiming to better child conditions in the city, and to-
gether a good deal was accomplished.
The real campaign against infant mortality, however, may
be said to have begun in 1908, when the Division of Child
Hygiene of the Health Department was organized, to which
all the work done by the Department for infants was en-
trusted. An attempt was made for the first time to coordinate
the different agencies working in the city for the same end,
by a series of conferences on the Summer Care of Babies,
which were largely attended. The summer corps was in-
creased to a force of 28 paid medical inspectors and 111
nurses. The city was divided into 89 districts and an effort
was made to reach all sick infants in the poor districts. For
the first time visits were made by nurses to tenement homes
in which births were reported, and instruction and advice
given. Talks to mothers were given in many centers on the
hygiene and feeding of their infants and much literature dis-
tributed. The campaign was continued for four and one-half
months in the place of three months as formerly. Seven milk
depots were opened by the New York Milk Committee, and
others by private agencies.
Work along much the same lines was continued during 1909
and 1910, each year witnessing better organization and more
effective service. By 1911, most workers in this field having
become convinced by the experience of the last three or four
years of the value of the milk depot as an agency for saving
babies in summer, an increased number of such stations were
opened. 29 In all, 79 were operated throughout the season 15
by the Health Department, 31 by the New York Milk Com-
mittee and 33 by various other organizations or by individ-
uals. Some 150 different bodies working for child welfare
L. EMMBTT HOLT, M. D.
51
or public health were federated in an Infant Welfare Associa-
tion, thus securing harmony, cooperation, preventing duplica-
tion of effort and fixing standard methods of working and of
recording results. This organization, afterward known as
"The Babies' Welfare Association," has been, and still is, a
powerful factor in the results obtained in New York. It has
unified effort, and, through its efficient secretary, it has en-
listed the cooperation of the press and done much to arouse
public interest and shape public policy.
WHAT HAS BEEN ACCOMPLISHED IN NEW YORK
The results shown at the end of the year were a surprise to
even the most sanguine. For the preceding seven years the
average infant mortality had been 16,527; only once was it
below 16,000, and it had been as high as 24,000. In 1911 it
fell to 15,030, a reduction of 1,184, or nearly 8 per cent from
the previous year.
During 1912 essentially the same campaign was waged not
only during the summer months, but throughout the year.
This season the majority of the milk stations (55 out of 77
operated) were taken over by the Health Department. The
remarkable record of the previous year was again lowered.
The total infant deaths for the year were but 14,289, a reduc-
tion of 741, or nearly 5 per cent from the low figures of 1911.
Could the results of 1911 and 1912 be repeated in 1913?
Many were skeptical, not a few thought it impossible. The year
has not yet closed, but for the first ten months, ending Novem-
ber 1st, and including the period of highest mortality, the
records of the two previous years have been surpassed. For
this period there have been 492 less deaths than in 1912 for
the same months.
The results above mentioned are even more striking when
the rate is taken in comparison with the infant population
for the different years : 28
In 1880, the infant death rate was 288 per 1,000 of living infants.
In 1902,
In 1908,
In 1911,
In 1912,
In 1913, ' ' ' 102 1,000 ' " (estimated from
records of first ten months).
These results have not been accidental. They have been
brought about by hard work enthusiastically carried on, but
most of all by a carefully planned campaign in which the re-
168
1,000
144
1,000
120
1,000
109
1,000
102
1,000
52 INFANT MORTALITY
sources of the city have been concentrated upon a definite
object. Furthermore it must be added, by liberal appro-
priation on the part of the city authorities ; without this such
results would, I believe, have been impossible. What has been
accomplished in New York has been approached in other cities
of the United States, and just in proportion to the extent of
the operation of life-saving agencies similar to those used
in New York. Thus, while New York has shown for the first
ten months of this year a reduction of 4 per cent from last
year, Chicago for nine months shows an increase of 5 per cent
and Philadelphia an increase of over 11 per cent from 1912.
The essential parts of New York's campaign have been :
Visits by trained nurses to the homes of ignorant mothers
of newborn babies.
Extensive development of the milk depot, and infant con-
sultation.
Federation in one organization of all the agencies engaged
in infant welfare work.
Efforts in other cities to be successful must be made along
these or similar lines. The time when individual effort can
cope with this problem has passed. The present conditions
call for an organized campaign, planned on scientific lines
and carried out with business-like efficiency. Only such effort
can meet the complex situation as it exists in our large cities
today.
ESSENTIALS IN AN INFANT MORTALITY CAMPAIGN
The general motto must be,, as often said : concentrate effort
on the mother ; assist maternal nursing whenever possible by a
stipend or by pensions when necessary. If artificial feeding
becomes necessary the mother must be taught it with patience
and intelligence. But whether nursed or fed, infants must
be kept for the first year under close and continuous observa-
tion of trained workers. The time was in the not distant past
when if parents did not choose to send their children to
school they were allowed to keep them at home, and even
put them to work. Modern public opinion, however, has de-
creed that in a sense the child is the ward of the State and
ignorant parents are no longer to be allowed to exercise their
parental rights in such matters. The State steps in and as-
sumes to decide how much schooling a child shall have and
to see that he gets it. Until recently also the authority of
parents over the health of children and the control of condi-
L, EMMETT HOLT, M. D. 53
tions which affected it was considered to be unquestioned,
and only in matters of contagious disease did authorities inter-
fere. But we are now coming to see that the child belongs to
the State in this respect also, and that the right of a mother to
neglect or starve her infant or feed it bad milk may come to
be regarded as an offence against society such as we now
regard absence from school. What parents will not do volun-
tarily the State will either compel them to do or will step
in and do for them. Infants will not be permitted to die
from neglect and bad feeding, nor will conditions be tolerated
which make it possible that a large percentage of infants who
grow up in cities live in such surroundings that health and
normal physical development is simply impossible.
We have seen the early disregard of infant rights and the
indifference with which society regarded infant life. We have
traced the gradual growth of the idea that the child was
valuable to society, to the State. We have seen how little
was accomplished to save infant life through efforts which
were guided by human sympathy and pity alone.
What they have failed to do modern science and organi-
zation have accomplished. By them the seemingly impossible
has been achieved. What of the next step? Our work is to
be largely a campaign of education, which shall carry into
every city and town of the land a knowledge of what can be
done and how to do it. That is the chief function of this
Association to create a public opinion which shall make such
an infant death rate as has been seen during recent years in
many of our manufacturing cities never again possible. Such
conditions are not only a stigma upon that especial com-
munity, but a disgrace to the country at large. Looking
at the magnitude of the problem presented by infant mortality
in our large cities today, we, who are working for better
conditions, stand aghast at the difficulties which confront
us, but a review of the great advances which have been made
in recent years gives us new courage and new hope for the
future. We have seen in the last twenty-five years more ac-
complished in this direction than had been done in the previ-
ous two hundred and fifty years; I think one might truth-
fully say in the previous fifteen hundred years.
Does God fix the death rate? This question has recently
been raised in several journals. Once men were taught so,
and death was regarded as an act of Divine Providence,
often inscrutable. We are now coming to look upon a high
infant death rate as evidence of human weakness, ignorance
54 INFANT MORTALITY
and cupidity. We believe that Providence works through
human agencies and that in this field, as in others, we reap
what we sow no more and no less.
The motto of the New York Health Department should be
the creed of all interested in this subject: "Public health is
purchasable; and within certain natural limits each commun-
ity may determine its own death rate."
BIBLIOGRAPHY
1. 69th and 73d Annual Reports, Registrar-General, London, 1908 and 1912.
2. Position of Woman in Ancient Greece and Rome, James Donaldson, New
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3. La Protection de la Premifcre Enfance, J. A. Duche*, Paris Thfcse, 1909.
4. Essai sur L'Histoire des Enfants-Trouve~s, M. de Gouroff, Paris, 1829.
5. Diseases of Children, Underwood, London, 1806.
6. Sur la mortalite" des Enfants du Premier Age, J. Comby, Le Progres Me'dical,
1885.
7. La Mortality des Enfants Nouveau-Ne's dans les Differents Pays, Congrfcs
International d'Hygifcne, Vol. I., Paris, 1878.
8. Considerations sur les Enfants-Trouve's, Benoiston de Chateauneuf, Paris,
1824.
9. Observations on the Mortality and Physical Management of Children, John
Robertson, London, 1827.
10. The Infant, the Parent and the State, H. Llewellyn Heath, London, 1907.
11. Infant Mortality, George Newman, London, 1906.
12. Some of the More Prominent Causes of Excessive Infant Mortality, William
Moore, Dublin, 1861.
13. Medical Essays, Thomas Percival, Warrington, England, 1789.
14. Archives G6nrales de Medecine : 10, 1826, p. 461.
15. Historical Sketch of Medicine and Surgery, William Black, London, 1782.
16. Essay upon Nursing, William Cadogan, London, 1749.
17. A Cursory Inquiry into Some of the Principal Causes of Mortality among
Children, John Bunnell Davis, London, 1817.
18. Mortality of Children in the Principal States of Europe, William Parr,
Journal Statistical Society, Vol. XXIX., London, 1866.
19. Essay on Milk, Robert Hartley, New York, 1842.
20. La Origine de la Creche, Revue PMlanthropique, Vol. IV., 1898-99.
21. Mortalite" des Enfants Nouveau-Ne's, CongrSs International d'Hygiene, VoL I.,
Brussels, 1876.
22. Dangerous Trades, Thomas Oliver, London, 1902.
23. Infant Mortality and Necessity of a Foundling Hospital In Philadelphia,
John S. Parry, Social Science Association, Philadelphia, 1871.
24. Infantile Mortality and Infants' Milk Depots, McCleary, London, 1905.
25. Dr. L. E. La Fetra, personal communication.
26. The Children of the Nation, John E. Gorst, New York, 1907.
27. Phases in Development of Infant Welfare Movement in England, Janet Laue-
Claypon, Trans. 15th International Congress on Hygiene, Vol. III., Sec-
tion III., Part 1, Washington, 1912, p. 388.
28. Reduction of Infant Mortality in N. Y. City, Josephine Baker (ibid.), p. 139
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by Philip Van Ingen.
REPORT ON THE ENGLISH SPEAKING CONFERENCE ON
INFANT MORTALITY
By HE1VRY Li. COIT, M. D., Chairman, American Committee
Following a suggestion made at the Berlin Congress on In-
fant Mortality in 1911, the British Association for the Preven-
tion of Infant Mortality and for the Welfare of Infancy,
organized an English Speaking Conference on Infant Mortality
which was held in London, August 4th and 5th, 1913.
The Conference was under the patronage of their Majesties,
the King and Queen and the presidency of Bight Hon. John
Burns, Member of Parliament and head of the Local Govern-
ment Board.
The Committee on Organization consisted of Sir Thomas
Barlow, Chairman, Sir Lauder Brunton, Alderman Benjamin
Broadbent and others, assisted by an American Committee
authorized by this Association and appointed by President
Holt, of which the writer was chairman and Dr. Philip Van
Ingen was secretary.
The sessions, of which there were nine, arranged under
Administrative and Medical sections, were held in Caxton
Hall, Westminster. There was a general opening session and
two morning and two afternoon meetings where papers were
read by distinguished delegates sent to the Conference by
their respective governments, institutions, medical and philan-
thropic societies.
Practically every English speaking country in the world
was represented. The governments of twenty-three different
countries appointed in all twenty-nine special delegates, in-
cluding Sir Charles F. Lukis, Director General of the Indian
Medical Service ; Dr. Charles A. Hodgetts, Medical Advisor to
the Canadian Commission of Conservation; Dr. W. Perrin
Norris, Chief Medical Officer of the Australian Commonwealth,
Medical Bureau; the Agents General of New South Wales,
Queensland, South Australia and Victoria; the Hon. G. H.
Butler, Chief Secretary for Tasmania ; Assistant Surgeon Gen-
eral, John W. Kerr of the United States Public Health Ser-
vice ; Mr. Sherwin C. Kingsley of the Children's Bureau of the
Department of Labor of the United States, and Superintendent
C. E. Meleney of the New York Department of Education.
Many societies, hospitals and a large number of institutions
were represented by delegates. These included schools for
mothers, national and local health societies, training colleges,
etc., including every form of welfare work for mothers and
infants.
About two hundred public health authorities in the British
Isles, appointed one or more representatives, who were present.
55
56 REPORT
The United States, through its Committee and efficient secre-
tary, secured the membership and attendance of about fifty
persons, most of whom were physicians who are engaged in
American activities for the conservation of infant life.
The total membership of the Conference was six hundred
and about this number was in attendance upon the sessions.
At the opening general session, the Eight Hon. John Burns,
presided, welcomed the visiting delegates and presented an
inaugural address on infant mortality. The address was com-
prehensive and showed a remarkable familiarity with the scien-
tific aspects of the question. He emphasized the importance
of co-operation of all English-speaking peoples in conserving
the health of their infant population and urged that the simi-
larity of life, language and ideals called all to the common
duty of conserving the health of their children. He stated
that last year 300,000 persons left the British Isles for
America, Australia and New Zealand. He mentioned the ad-
vantages of the country over the cities as a place to rear
healthy children and analyzed statistics to show that the phy-
sician was the logical leader in the crusade against infant
mortality.
It was stated that the infant death rate was lowest in phy-
sicians' families, it being only 40 per thousand. In the upper
and middle classes it is 77 per thousand, whereas among arti-
sans it is 100 to 130; among miners, 160 and in the case of
unskilled workers, 150 per thousand.
The inaugural address was followed by the greetings of offi-
cial representatives from the United States, India, Canada,
Australia and New Zealand.
At the close of the joint session, members of the Administra-
tive section assembled in the large hall on the ground floor and
those of the Medical section in the council chamber on the
second floor, to listen to the papers presented to the conference
by delegates appointed to read them.
The papers were limited to 2,000 words. At the first Admin-
istrative Session, Arthur Newsholme, M. D., medical officer of
the Local Government Board was Chairman. The subject was
"The Responsibility of Central and Local Authorities in the
Matter of Infant and Child Hygiene." Papers were read by
Dr. F. E. Fremantle, of Hertfordshire; Dr. Charles A. Hod-
getts, of Ottawa ; Prof. Eichard Caton, of Liverpool ; Dr. H. J.
Gerstenberger, of Cleveland, and a paper written by Miss Julia
C. Lathrop of the Federal Children's Bureau, of Washing-
ton, D. C.
At the second Administrative Session, papers were read" by
Mrs. Kitson Clark, of Leeds; Dr. Helen MacMurchy, of
HENRY L. COIT, M. D. 57
Toronto ; Mr. James Gray, of South Australia ; Dr. David For-
syth ? of London, and Dr. H. L. K. Shaw, of Albany.
At the first Medical Session the Right Hon. Joseph Pease,
M. P., President of the Board of Education, was chairman.
The subject was "The Necessity for Special Education in
Infant Hygiene." Papers were read by Dr. L. E. La Fetra, of
New York; Dr. C. Paget Lapage, of Manchester; Dr. F. Truby
King, of New Zealand; Miss Alice Gregory, of England, and
Dr. Caroline Hedger, of Chicago.
At the second Medical Session, Sir George Newman, M. D.,
Medical Officer of the Board of Education, was Chairman.
The subject was "Medical M.ilk Problems" Papers were read
by Dr. Henry L. Coit, of Newark, N. J.; Dr. Eric Pritchard,
of London; Dr. A. E. Naish, of Sheffield; Dr. Fritz B. Talbot,
of Boston; Dr. Frederick Langmead, of London, and one
written by Dr. G. E. Pisek, of New York.
At the third Administrative Session, the Countess of Aber-
deen, was Chairman, the subject was "The Administrative
Control of the MilJc Supply" Papers were read by Prof. J. M.
Beattie, of Liverpool; Assistant Surgeon General John W.
Kerr, of Washington; Dr. William G. Savage, of Somerset-
shire; Dr. E. W. Hope, of Liverpool, and Mr. J. W. Brittle-
bank, of Manchester.
At the third Medical Session, Dr. Charles A. Hodgetts, of
the Canadian Conservation Commission, wa^ Chairman. The
subject was "Ante-Natal Hygiene." Papers were read by Dr.
J. W. Ballantyne, of Edinburgh; Dr. Philip Van Ingen, of
New York ; Mrs. Fowles, of Birmingham, and Dr. F. W. Mott,
of London.
At the fourth Medical and final session, a paper written by
Dr. Barbara Sutherland, of Glasgow, was read by Dr. A. K.
Chalmers ; a paper written by Dr. J. L. Huntington, of Boston,
was read by Dr. E. Green ; one by Dr. J. M. Monroe Kerr, of
Glasgow, and one written by Dr. Macleod Yearsley, of London,
was read by title.
The transactions, including the full text of the papers have
been published and may be obtained from Miss J. Halford,
Secretary, 4 Tavistock Square, W. C., London, the price being
three shillings net.
The conclusions of the Conference were expressed in the
followings Eesolutions, which were passed unanimously at a
joint session of the sections, on August 5th, 1913 :
Resolved, That tMs Conference urges that the Maternity Benefit be
made the property of the mother both in practice and in law.
THAT the attention of the Board of Education be drawn to the
extreme desirability of making the grant earned by "recognized" Infant
Welfare Centres depend in future on their efficiency, on the number
58 REPORT
of registered attendances of the mothers at Consultations, Classes and
Talks; and on the number of home visits paid under adequate super-
vision.
THAT in view of the damage liable to be wrought in growing girls by
injudicious stress of education, especially during puberty and adoles-
cence, this Conference feels bound to deprecate any form of education
for girls which pays insufficient attention to establishing good bodily
health and development and complete fitness for maternity and the
practical care of a home.
THAT this Conference urges upon the Government the necessity
in the interests of both mother and child of legislating for the regis-
tration of stillbirths.
THAT this Conference urges upon the Government the necessity for
the more complete medical certification of death, and that the medical
death certificates should be forwarded to the registrars, as confidential
documents under sealed cover.
THAT the time has arrived for steps to be taken with a view to
securing the better training of women who apply for the certificate of
the Central Midwives Board.
THAT this Conference requests the Executive Committee to communi-
cate with the General Medical Council and the degree and license con-
ferring bodies with a view to infant hygiene being given a more
important place in the medical curriculum.
In view of the large percentage of stillbirths and infant deaths
directly attributable to venereal diseases and considering that infant
blindness and other congenital defects are in many cases due to the
same cause, the English- Speaking Conference on Infant Mortality urges
the respective Governments of the countries therein represented each
to appoint a commission to inquire into the prevalence, the causes, the
provision of treatment and the possibility of the prevention of these
diseases.
THAT the Executive Committee be instructed to take whatever steps
it may think desirable in order to insure a microscopical examination
of milk, to be supported by analytical methods.
The Committee on Arrangements made adequate provision
for the entertainment and comfort of all delegates. Provision
was made for visits to all institutions in London and vicinity
where infants and young children are cared for,
A public dinner was laid for members, their ladies and guests
at the Hotel Grand Central, which was followed by an informal
reception. A reception was given to the members and their
friends by the Duchess of Marlborough at Sunderland House,
From every point of view, the English-Speaking Conference
on Infant Mortality was a signal success. The attendance was
large, the arrangements perfect, the spirit harmonious and the
interest in the proceedings very great. Eepresentatives from
all English-speaking countries were in accord in fostering a
spirit of modern social and scientific progress. It was found
that the interests of all were parallel, fundamental principles
were identical and the ideals to be attained were on the same
mountain.
SESSION ON NURSING AND SOCIAL WORK
Friday, November 14, 11 A. M.
COMMITTEES
CHAIRMAN
MISS HARRIET L. LEETE, Cleveland
SECRETARY
MRS FRANCES FREESE LICHTENSTEIN, Cumberland
MISS MINNIE H. AHRENS, Chicago
MISS M. FRANCES ETCHBERGER, Baltimore
MISS ZOE LA FORGE, Detroit
REPORT OF THE COMMITTEE
FRANCES FREESE LICHTENSTEIN, Secretary
Two questionnaires have been sent out. The first to learn
the extent of special training available to prepare a nurse
for the care of infants. Detailed conclusions drawn from the
replies will be discussed under "Standards for Infant Wel-
fare Nurses."
The second questionnaire was for the purpose of getting
in touch with all nurses specializing in baby work; to secure
detailed reports of their work; to ascertain as nearly as pos-
sible the number of nurses doing infant work exclusively;
how many are taking up prenatal care ? and what special
qualifications and preparations the various organizations are
requiring of their nurses.
Letters were sent to seventy-five organizations known to
be doing infant welfare work. Forty replies were received.
Twenty-five of these reported that they specialize in baby
work.
All except the Division of Child Hygiene of the New York
City Department of Health and the Division of Child Welfare
of Toronto Department of Health are under some sort of pri-
vate control. A few are under both private and municipal
control.
In two cities, Cumberland, Maryland, and Evansville, Indi-
ana, the work is just starting and no reports have been is-
59
60 REPORT
sued. Seven only, make a note of prenatal care. The report
from the Babies' Dispensary Guild of Hamilton, Ontario,
says, "efforts are being made to broaden the work along pre-
natal lines. Classes are being held weekly for expectant
mothers."
The Washington Diet Kitchen, D. 0., and the Babies' Hos-
pital, of Philadelphia, have "plans for the future to afford
prenatal instruction."
It was difficult to get the number of nurses specializing
in infant welfare work and more difficult to get the names
and addresses of these nurses. Some associations sending out
lengthy reports of very excellent preventive and relief work
make no mention of their nursing staff and the name of their
supervising or head nurse appears nowhere within the pub-
lication. However, it is assumed from the text of the report
that much of the actual labor is being done by some one
having had hospital training. It is probable that some or-
ganizations gave the total number of nurses doing all kinds
of visiting and social work rather than the number working
with infants only. However, as the reports stand, one hun-
dred and seventy-three were reported in the United States,
two in Hamilton, Ontario, and over two hundred connected
with the Victoria Order of Nurses.
Almost all organizations require an eight hour day of
their nurses. In Boston and in Utica ten hours are required ;
Philadelphia, eight and one-fourth; Chicago, eight and one-
half; and Washington, D. 0., only seven.
The qualifications required of nurses to fit them for this
work are by no means uniform. Almost all require a diploma
from a school giving at least a two years' training. None have
made mention of special ability to teach or instruct. A few
said "we cannot expect to get nurses with special training for
the salary we pay."
The New York Department of Health and the Washington
Diet Kitchen require registration. One organization demands
good judgment and character. The Babies' Milk Fund Asso-
ciation of Detroit and the Infant Welfare Society of Chicago
mention special ability for baby work and special training
with children. These two are the only organizations that men-
tion either. I think we may conclude that not much has been
demanded in the way of qualification for one of the most im-
portant branches of work done by the nursing profession.
The other questionnaires may show that the schools are not
providing this special training. The papers also lead me to
F. F. LICHTBNSTBIN 61
believe that the salaries offered by most of the organizations
are not sufficiently large to induce many to go in for special
training for special work, after the usual period of general
training is over. I am sure all of us, in our hospital experience,
have seen many women with a special fondness, a special
ability, an inborn understanding of baby life, and on the other
hand have seen others who were excellent women, capable
nurses, but not attracted at all by the work in the baby wards.
If the former could be singled out by their head nurses and
superintendents and encouraged to investigate this line of
nurses' work, if their training could be laid out with this in
view, I believe the infant welfare work would profit thereby.
STANDARDS FOR INFANT WELFARE NURSES
ZOE LA FORGE, Superintendent of ffurses, Babies' Milk Fund
Association, Detroit
In discussing standards for Infant Welfare Nurses we must
know something about the kind of training and the methods
of teaching in the preparation for such work. An effort was
made to collect such information by means of a questionnaire
sent to 75 hospitals. Eeplies were received from 49 hospitals ;
six of which were special, classified as maternity,, infants' and
children's. A summary is given as follows, from which our
conclusions are drawn. First, the general hospitals:
A minimum educational requirement for 21 schools is one
year in high school, and 14 require that the applicant shall be
a high school graduate. One requires, in addition, a four
months' preliminary course in the university with which the
hospital is connected. The length of probation ranges from
one month to one year, the average being three months.
The number of infants' beds, 6 did not state; of the remain-
ing 37, 27 have less than 30 beds, 22 less than 20 beds, and 7
less than 10; 34 of these are cared for in children's and matern-
ity wards ; 6 are in separate wards.
The time for practical work in wards, 9 did not state with
sufficient clearness to classify; 22 have from 1 to 3 months;
3 have 6 months, combining care of infants (obstetric service)
and children. Four hospitals have affiliated with special hos-
pitals for children, which unfortunately are not included in
the returns on the questionnaire. A comparison of standards
under the affiliation would be most interesting.
In theory, lectures and classes, 18 hospitals include in
12 lecture hours or less all instruction in infant care, infant
feeding, care of children, prenatal care, sanitation and hous-
ing. Ten more have from 1 to 6 hours on infant feeding;
12 have from 2 to 12 hours on care of children ; 5 have from
2 to 12 lectures on prenatal care. It is noteworthy that one,
the Long Island College Hospital, has lectures on sanitation
and housing by an expert a Board of Health official.
Breast-feeding is emphasized in 31 hospitals; 11 made no
statement, and one did not commit itself except that "the
doctor's orders were followed."
62
ZOE LA FORGE 63
The question regarding the kind of milk used evidently was
not clear; 34 did not answer it; 6 use certified milk, and 2
pasteurized for the modifications.
Sixteen have social service training in obstetric or infant
service.
Twenty-four expressed approval of a post-graduate course
for teaching and administrative work and public health work ;
6 more qualified their assent. There was an identical reverse
of opinion regarding special training in infant work for pri-
vate duty.
The length of the courses of training offered by the special
hospital varies from 3 months, a post-graduate course in
obstetrics and gynecology, to 3 years, a children's hospital.
The requirements for admission varied with, each school; a
common school education was required of the applicant to the
school for nursery maids ; a "fair education" of a second ; one
and two years of high school and a high school diploma of
three more; a hospital diploma of the sixth. The number of
beds range from 21 to 100 ? two having from 20 to 30.
The practical work covers a period of six months to one
year for infants, with the exception of the post-graduate course
in obstetrics. The work with children is from one year to
eighteen months.
Lectures and classes are classified in many ways, which
makes a careful tabulation somewhat difficult. However, there
is no doubt that the theoretical training is in just proportion
and balance with the practical work.
The obstetric hospitals qualify their assent to the question
as to the fitness of their graduates to specialize in infant
work, the one believes her capable of doing administrative
work and teaching. Four of the six are agreed that she
should have a post-graduate course for public health work.
Briefly, we have our general hospitals giving a training
three years long, fitting the average nurse for private duty,
and one special course requiring a service as long as the
general. For the best service in teaching, administrative, or
public health work she must supplement her training. The
theory and practice are both inadequate to prepare her for the
demands of specialization, which I shall attempt to show is
fully justified.
The spirit of the age is expressing itself in intensive develop-
ment. The facility of communication has made your morn-
ing newspaper with the generalities of the whole world's life
possible. Its very diversity makes selection and renunciation
constantly necessary. For the human mind to dissipate itself
64 STANDARDS FOR INFANT WELFARE NURSES
over the length and breadth of the suggestion supplied by daily
life would prove its destruction. Because of its own limita-
tions, because mental development iis achieved by growth
rather than mechanical elaboration, the mind must exercise
the right of choice, of selection in its activities which become
thereby special in character.
Let the imagination consider the various means of com-
munication: the telephone, telegraph, commerce, printing,
photography, moving pictures, each of which affect us all many
times daily in many ways, and the complexity of their ramifi-
cations. Their extent is quite beyond the imagination. Their
growth has been a development of specialization highly organ-
ized. Critics have warned us of over specialization, which
may be called rather a condition of immaturity. Professor
Charles Horton Cooley, in his book on "Social Organization,"
says: "Our world lacks maturity of culture organization.
What we sometimes call truly enough as regards its econ-
omic life our complex civilization, is simple to the point of
poverty in spiritual structure. ... A strenuous state of
mind is always partial and special, sacrificing scope to in-
tensity and more fitted for execution than insight. It is use-
ful at times, but if habitual cuts us off from that sea of sub-
conscious spirit from which all original power flows." The
dangers of over specialization are not to be overlooked. They
are most likely to grow from quick action and slow thought.
Professor J. Laurence Laughlin, of Chicago University, tells
us in a discussion on "Monopoly of Labor" that "Discontent
acts first and thinks afterwards." Specialization may, per-
haps, be considered a natural monopoly. Prof. Laughlin classi-
fies monopoly as natural and artificial. A natural monopoly
grows from conditions where efficiency is a part of the scheme,
and the higher position is earned by normal competition. The
artificial monopoly maintains the "dead level" theory, where
a man's a man, little brain or none, with equal share in the
earnings, and with specialization left out of the plan. The
most striking illustration is the labor union. I believe that
the future success of our work depends upon the adaptation
of the business of nursing to the principles of a natural
monopoly, or the perfection of specialization. Its growth to
the present time has laid emphasis upon a standard more
uniformly high and I believe we may continue to expect higher
aspects and greater progress. By such means does specializa-
tion justify itself.
It is equally true that the foundation for such growth must
be the breadth of life.
ZOE LA FORGE 65
The education of nurses and of all other women thus far
in the world's history has not given them the foundation which
should precede the special study. But from the present age
has grown the opportunity for women to develop such com-
prehensive organization as shall bring about a new era in
women's education. Its immediate bearing upon the educa-
tion of the nurse is obvious, since the majority of nurses are
women. The three great national bodies of nursing education
which met for the first time this year at Atlantic City are an
expression of this enlargement and quickening of mind ? and
I believe are an embodiment of the first essential to growth,
the co-ordination or unifying of the differentiated parts of
nursing work.
As the branch of the tree is supported by the body and
draws its life from the earth, so the specialized branches of
nursing grow from the complete body which is sustained by
life itself, in natural beauty and order.
The standards for Infant Welfare Nurses are those meas-
ured for all public health nursing work from which the
specialized work has sprung and for the hospital which is the
training school of nursing education. No more can water
rise above its level. The truth of what Miss Goodrich has
written upon the subject impresses me with such conviction
that I take the liberty of quoting her at some length. She
says: "If we would keep pace with the educational move-
ment we must keep closely in touch with the great educational
systems and see to it that they contribute a just proportion
of their riches to our important work. One of the heaviest
assets is the knowledge born of long experience of the stand-
ardizing of schools and to them we should turn when we
are considering establishing standards and the need of such
standardization cannot be denied. . . .
"I believe the two most important factors in raising the
standard of our profession are the quality of the pupil and
the strength of the faculty. I will go further and say that
since the quality of the pupil is in no small measure dependent
upon the strength, mental, moral and numerical, of the fac-
ulty, that the most important factor in our professional prog-
ress is the faculty of our schools. . . . The strength of
our schools of nursing has unquestionably lain in the drill-
ing and in mastering of details through the practical work
in the wards of the hospital. Must we not see to it that the
preparation of our nurses lies in the hands of women of vision
and must we not then go further and make it possible for
them to obtain the necessary assistance from every standpoint
66 STANDARDS FOR INFANT WELFARE NURSES
to efficiently carry on their schools? Says an authority on
education in a recent report : 'The first essential in standard-
izing is to determine the standard and having done that, to
place the enforcement of it in the hands of a competent body.'
We have in a few states found the competent body. . . .
"But if we have found or are finding the logical bodies of
control, are we not failing if we are not prepared to go to
them and say, these are the standards which we as a national
body, out of our experience, have determined upon as abso-
lutely essential for schools whose graduates are charged with
so great a responsibility as the public health? ... I
am not prepared to say that the principals of our schools shall
be college graduates, but I am prepared to say that if the
Teachers' College of Columbia University is demanding the
completion of college for women preparing as teachers in the
high schools, that we should not be willing to consider that a
nurse whose preliminary education was limited to one year of
the high school or an equivalent is educationally equipped to
take charge of a school of nursing. I have not stated what
the number, preparation or status of the faculty should be.
I do not think these are questions for one woman to decide,
but to be determined after careful study by a committee."
To summarize briefly in conclusion: the present training
schools, special and general, may be organized to supply each
other's deficiencies, that one may be the complement of the
other :
That specialization justifies itself when its foundation is
basic :
That the standards for Infant Welfare Nurses in common
with the entire body shall be determined by a representative
committee :
And that the highest standards may most efficiently be estab-
lished for the entire nursing body by the co-ordination of its
differentiated parts.
DISCUSSION
Professor M. Adelaide Nutting, New York: I am unprepared
to discuss this paper except with a general endorsement of
the proposition which Miss La Forge has brought forth. That
proposition is that we should in some formal way at this
meeting, if possible, give expression to our belief that training
in the care of infants and children is a very uncertain and
indefinite part of training school work at the present time;
and it is of paramount importance, if nurses are to do such
work well that they should be properly prepared. I don't
DISCUSSION 67
know what formal action this body may take. Perhaps after
listening to the rest of the papers you may feel like passing
up a resolution asking training schools to give greater atten-
tion to the training of nurses for this work. In every branch
of nursing, training in the care of children is essential.
Miss Anna W, Kerr, New York; While I think we are all
agreed that we must not fix our ideals too high, I think we are
agreed that the training of the nurse at the present time is not
just what is should be; and that our public health work should
enter into her training. I think we should take up the sub-
ject of a post-graduate training school soon. Our nurses in
New York are technically pretty well trained, as we have
developed the social aspect of the work, and give four or five
months to the training of these nurses for public health work.
That does not seem to be fair to the city. The educators of
New York have considered that subject. We hope in the near
future they will establish a post-graduate training school in
some large centre where half of the day can be devoted to
field work and the other half to study in either the Teachers 7
College or some other place where it is practicable.
Miss Nutting: May I ask Miss Kerr, who is supervisor of
the nurses in the Public Health Department of New York City,
whether she thinks it would be practicable for nurses to have
a half day of training in the Department and to have their
theoretical work given elsewhere?
Miss Kerr: I think it might be worked out half a day
practical and half a day theoretical work for a short period
of time to include all field and public health work, preven-
tive work, etc. This is a very large field and requires a great
deal of social training.
Miss Nutting: This points to a possible way for those
women who have not time to spend a full year in post-graduate
work.
The Chairman: This question is of paramount importance,
and requires most careful consideration.
Miss Kerr : They are having a special course of lectures for
supervising nurses in the Teachers' College and the School of
Philanthropy in New York this year. The working nurses have
a special course prepared for them aside from our depart-
mental teaching.
68 DISCUSSION
Dr. Helen C. Putnam, Providence : The suggestion has been
made that graduate nurses might receive special training in
continuation schools, to become visiting nurses and for other
specialties. I think if anything were to be done, next year
would be the time for taking some action; because these are
the years when continuation schools are being organized. It
will be much easier to incorporate something into their cur-
ricula now than later, when they have become fossilized.
Mrs. William Lowell Putnam, Boston : Is there any one here
to report on nursing in Massachusetts? In the Waltham
Training School the nurses have a part of their regular train-
ing in the houses of the people of the neighborhood before they
get their diploma. The Instructive District Nursing Associa-
tion, of Boston, carries on a training school in district nursing
for graduate nurses. My pre-natal nurse has been supervising
the pre-natal work of this Association, teaching their pupils
this branch of work.
The Chairman: I think there is a nine-months' course. Is
there some one here from Boston who can answer that ques-
tion?
Miss Fannie F. Clement, Washington: There are two courses
in Boston in connection with the Instructive District Nursing
Association; one a four-months 7 course under supervision of
the Association, and the other an eight-months' course given
in affiliation with the Boston School for Social Workers. The
nurses give two-thirds of their time to the School for Social
Workers and one-third for practical instruction to the District
Nursing Association.
PRIVATE BITTY NURSES AND THEIR WORK IN HELPING TO
PREVENT INFANT MORTALITY
MISS M. PRANCES ETCHBERGER, Baltimore, Md.
In this day of earnest seeking after the highest develop-
ment of the human race, the opportunities to be found in the
daily life and work of the private duty nurse cannot be over-
estimated. The realization of this brings to us the question
of whether or not the general training of the average nurse
entirely fits her for the important and necessary teaching in
the home.
The nurse undoubtedly conies in contact with all classes
of our population, and by the example she sets and the
duties she performs, teaches directly and concretely the ele-
ments and principles involved in our fight against preventable
diseases and afflictions of childhood.
The physician who decides to specialize in any field, studies
along the particular lines selected, after finishing the general
work of the medical schools. Why cannot the training schools
give more attention in the same way to broadening the oppor-
tunities of the nurse for the very necessary baby work ? True,
she has her obstetrical training, but the baby is generally
about two weeks old when it leaves her care. Sometimes she
is fortunate enough to be connected with a hospital which
has a children's ward, but too often she receives her diploma
and is sent out on an unsuspecting public with less knowl-
edge of vital things connected with the baby, than the mother,
who will naturally depend upon her words as golden.
General education of the public in regard to the conserva-
tion of human life through baby welfare work (prenatal and
postnatal) would constitute an economic force in the world's
future. A movement which would fit all nurses to cooperate
with the specialist in the fight against infant mortality would
do more in a few years than has been accomplished in a gener-
ation, if properly and vigorously handled.
Personally, I trust the suggestion contained in the letter
addressed by the Secretary of the New York Academy of
Medicine to the American Nurses' Association will be success-
fully carried out, and a careful study of the various training
69
70 PRIVATE DUTY NURSES
schools for nurses be made. Such an investigation will find
the superintendents of the training schools aware of the defi-
ciencies of the present system, as was evidenced by the plans
outlined by Miss Nutting, and adopted by the National League
of Nursing Education in 1911.
The first two points, I feel are the most important for me to
touch on, viz:
(a) "By each superintendent arranging in her own school
for at least three lectures by experts on the causes
and prevention of infant mortality, physical, social,
industrial and economic."
(ft) "By securing for her pupils, at any effort, adequate in-
struction and experience in this important branch of
work."
Nurses in Baltimore are most fortunate in having in their
midst such important institutions as the Harriet Lane Hos-
pital for Children and the Thomas Wilson Sanatarium for
Children, where babies are sent during the summer months
and which offers an unusual opportunity for studying and
training along special baby lines.
Post graduate courses in baby welfare work, wherever pos-
sible, should also be encouraged and with special attention
during at least a few months of her training, the private duty
nurse would be sent from her school equipped to spread the
gospel of the proper care of the child the value of breast
feeding home modification of milk (if this is necessary),
a certain amount of knowledge of food values at all stages of
child life, and the proper preventive work necessary to the
development of the healthy boy and girl, in this way living
up to the important law "race preservation," which should be
the "first law of nature."
At the present it is a deplorable fact that the children of
the prince and the pauper are getting the best scientific care
the former, because of the ability to pay for the best medical
attention of the specialist, who naturally surrounds himself
with a staff of trained helpers, the latter, because of the won-
derful growth of public health nursing, which has so materially
changed the conditions of our by-ways and alleys.
This leaves the great majority of the public, who need and
feel they are getting the best help possible, when a graduate
nurse is called to the home, and to fit that nurse to make this
truly the condition, is our aim.
The time has now passed when the consideration of the
private duty nurse as an important element in the fight for
race advancement (through the reduction of infant mortality,
DISCUSSION 71
and the spread of knowledge necessary to the growth of healthy
children) seemed to be an ideal, the theory has now been
worked out and the practical evolved. But the work must
still be pushed, and the future will find the private duty nurse
even a greater force for good in the near future than the past
has known.
DISCUSSION
The Chairman: A resolution was passed by the Superintend-
ents' Society when Miss Cutting was chairman of the commit-
tee, expressing the hope that the private duty nurse could ren-
der some assistance to the public health organizations. If
there is any one present from any city in which the private
duty nurse is working in close connection with the public
health work, we would like to hear from her.
Miss Estelle L. Wheeler, Washington: I want to endorse every-
thing Miss Etchberger has said about the need of more train-
ing for pupil nurses in infant work. The private duty nurse
goes into many homes and is constantly being questioned by
friends and patients about the care of infants ; the nurse who
has had little or no experience during her training is fre-
quently embarassed. I do not believe that successful private
duty nurses have either the time or strength to do volunteer
work in day nurseries, baby clinics, milk stations, etc., as has
been suggested; this should be done while the nurse is sti]l
in training, then every nurse would have practical as well as
theoretical knowledge of the care of infants.
Miss Minnie L. Ahrens, Chicago : In Chicago one training
school has already made, as part of its curriculum for third-year
pupils, arrangements to spend a month in some phase of this
work. We have just had our first pupil from this school. She
has been a month in our work, and when she finished, I said,
''Will you do public health or private duty work?" She said,
"Private duty, and what I have seen this month will make me
do it from an entirely different point of view than if I had not
had this training." Although she may not do public health
work, the private duty nurse needs this training. Some schools
also send social service nurses to visit the different lines of
work in the cities ; sometimes it is with a school nurse, some-
times with an infant welfare nurse.
Dr. S. Josephine Baker, of New York: I wish to say a word
on the relation of the health boards and district nurses asso-
ciations on the question of training nurses for public health
72 PRIVATE DUTY NURSES
work during the time they are in training school. The training
in the hospital includes what we might call the "laboratory"
work of nursing, that is, the work at the bedside where the
nurse receives practical instruction. As no series of lectures
would fit a nurse for private duty, so no series of lectures
will entirely fit her for public health nursing work. She
must have some additional laboratory work in connection with
her theoretical training in the hospital. This so-called "lab-
oratory" or practical work can be furnished by boards of
health and social service agencies and these latter should be
used liberally. I am glad to endorse what Miss Kerr said.
There is no reason why we who are doing public health work
should not provide for you nurses all of the opportunities we
can. In all lines of public health work in connection with the
training schools for nurses the boards of health must serve
for field work and during the time of their training the
nurses should spend at least half a day for three months or
more in outside practical instruction _pf this nature. I believe
that Miss Nutting's suggestion should be very carefully fol-
lowed and I move that the Chairman be empowered to appoint
a committee of three to draw up resolutions calling the atten-
tion not only of the training schools, but of the health depart-
ments also to the need of preliminary training of nurses in
public health work and asking them to urge such curricula
in training schools that this training may be easily afforded
to the nurses before they are graduated. Although a nurse
may not go actively into public health work, she will in this
way get a broad and general understanding of work of this
nature and such an understanding will promote a close cooper-
ation that must take place if we are to get the full measure
in the reduction of infant mortality.
Seconded by Miss Nutting and unanimously carried.
The Chairman appointed as said committee : Miss Kerr, Miss
Lent and Miss La Forge.
The Chairman: We all know that there should be more
training. But I am sometimes sorry for the hospital super-
intendent who is always told how each line of work should be
developed more. I wish Miss Nevins would tell us something
about the difficulties of the Superintendents of Training
Schools.
Miss Georgia M. Kevins, Washington : I agree with all that
has been said, and I believe that the training schools are
waking tip to the fact that we must make every effort to estab-
DISCUSSION 73
lish special courses for those students who have fitness for
public health nursing. Personally, I shall do all that I can
in that direction.
Miss Nutting: Would a request of this kind sent to the
boards or committees of training schools be of any substantial
aid to superintendents ? Or would it be more of a hindrance ?
Miss Kevins: I have never suggested an improvement of
any description to my board of directors that they were not
more than willing to grant.
Miss Clement: I wish to speak of the need of training for
the visiting nurse in a rural community with special reference
to infant welfare work. Very few rural nurses do any pre-
natal visiting and in other respects what infant welfare work
is done is not carried on as such or is at all systematic.
Through an investigation of opportunities for the training of
Red Cross visiting nurses we found a few of the visiting nurs-
ing associations cooperating with local boards of health in
the training of public health nurses. The Visiting Nursing
Association in Richmond, Va. ? is receiving most cordial co-
operation from the local Board of Health. The recent four
months' course established by Teachers' College and Henry
Street Nurses' Settlement in preparation for Red Cross visit-
ing nursing, includes affiliation with the New York City
Board of Health. The nurses spend one month of the four
working under supervision of this department, getting in
touch with school visiting and infant welfare work. In addi-
tion to two months at Henry Street Settlement, nurses taking
this course spend one month with the rural nurses in Northern
Westchester District Nursing Association, New York. The
University of Virginia is planning opportunities for nurses to
prepare for public health nursing and courses are being con-
sidered in other sections of the country in connection with
boards of health, colleges and other educational institutions.
Dr, Lilian Welsh, Baltimore : I have thought a great deal
about the character of the instruction given in the Nurses 7
Training Schools in the subject of hygiene. These schools are,
so far as I know, the only vocational schools in which the
teaching is done by teachers not trained for teaching, that is
by individuals who are only incidentally teachers. Then, too,
the nurses in training are only incidentally students. They
have neither time nor opportunity, to do any real work upon
74 PRIVATE DUTY NURSES
the subjects in which they receive didactic instruction. My
work in teaching hygiene to college students has made me
familiar with the text-books prepared for nurses in anatomy,
physiology and hygiene, and they are all inadequate at least,
I have found none I could use in my own classes. Nurses cer-
tainly should have adequate courses in personal, community
and racial hygiene based on a biological foundation, course
well organized, and given by some person specially qualified
to teach and whose work is to teach and to do nothing else.
The Chairman: I think the nursing and health department
of Teachers' College trains nurses for teaching.
Mass Nutting; There are now several teachers in our field
who are prepared to teach elementary biology.
INFANT MORTALITY NURSING PROBLEMS IN RURAL
COMMUNITIES
FANNIE F. CLEMENT, Superintendent American Red Cross Town
and Country Nursing: Service, Washington, j>. c.
The big field of study about Infant mortality in rural com-
munities of this country is yet so unexplored by nurses as well
as others, that a paper dealing with problems of the rural nurse
regarding this question must be restricted to the experi-
ences and conclusions of the meager few the pioneers in
country nursing. Little authorized investigation into living
conditions in rural communities has as yet been made, so that
definite statistics regarding infant mortality among this half
of our population upon which definite conclusions could be
based, are not yet available. The obligation of the rural nurse
to infant welfare work in her community is evident, however,
without this information at hand and she is trying to do her
share in giving to country mothers some of the advantages those
in the city with their easy access to hospitals, dispensaries,
infant welfare stations and settlements, receive.
The country-bred woman, when she becomes a mother, is often
handicapped in her care of the infant because of her environ-
ment, and the welfare of her child is affected by living condi-
tions more or less peculiar to the country. Housing conditions,
insanitary surroundings, and general mode of life in considera-
tion of the temperament of country dwellers, and the usual
absence of organized efforts in rural communities, creates for
the rural nurse obstacles she finds difficult to combat, and
which she meets frequently in localities where sick babies are
her most serious problem.
So fundamental in the infant mortality question is the value
and respect placed upon human life by the individual man or
woman, that I should like to speak first of this and its relation
to intentional miscarriages and self -induced abortions. It will
be impossible to get very far in carrying ou;t any constructive
plan until it is more generally believed that procreation is a
sacred attribute and the responsibility of developing a new life
is a consecrated trust. One of the resolutions made at the Eng-
lish Speaking Conference on Infant Mortality, held last sum-
mer in London, was that stillbirths be registered. If at the
75
7G NURSING PROBLEMS IN RURAL COMMUNITIES
same time it could be learned whether or not these were acci-
dental, I am led to belieye that such statistics in many of our
rural districts would disclose appalling conditions, and due to
one of the same causes that lead to the death of older babies,
a perverted sense of the obligations of motherhood.
The mother who does not want her child, and I do not refer
to the already over-burdened mother, is apt to be the kind of
woman who will not want to nurse it and devote her time to
mothering. It will be a difficult task to change her views, per-
haps, but to the young girls in the school and in their clubs
who do not imbibe proper thoughts upon this subject at home,
may be taught respect for their bodies, reverence for human
life, and the importance 'o<f intelligent motherhood. One of the
surest ways to prevent infant mortality is to school prospec-
tive mothers. An effort to do this is made by rural nurses, who
hold classes in home nursing. In their contact with young
girls they have a splendid opportunity to teach and discuss
such subjects as concern the future mother and the infant, and
these lessons will not soon be forgotten. In this work the
influence of a rural nurse is great and far-reaching. One rural
nurse has recommended the organization of physical culture
clubs for the young people as a means of instructing them
about their bodies. She organized the club, for which a special
instructor was engaged. It created a tremendous interest and
the mothers were so taken with the idea that they formed a
mothers 3 club during the same year, and are going to have
a class in physical culture for married women. The mothers
in their club were told of the habits of children, the diets
of infants, etc., and they found the talks of great help. This
same rural nurse has met with boy scouts and the school
children, to whom she has also given talks. It is so important,
too, that the fathers of the future receive their teachings that
are likewise so fundamental to the welfare of the next genera-
tion.
A nurse in a southern mountain community reports five mis-
carriages in one month in a village iof fifty families. This same
nurse, when she had been in her community about a month,
was presented with some black snakeroot by a woman, who in
the kindest way thought she was doing her a favor. She said
all the young women used it. A nurse in another southern
State, where she has been working for years, writes : "There
are many miscarriages which are generally intentional. Means
used are crude and dangerous, and after one or more, we find
our women having alarming hemorrhages and then soon become
invalids. Anyone trying to give an impression that there is
FANNIE F. CLEMENT 77
DO race suicide in the mountains is poorly informed and there
would be many more abortions if a way could be found.
Mioney is offered for this purpose that would be grudgingly
paid for a delivery. 77
Eegarding miscarriages in a Massachusetts village, a nurse
writes "They are tremendously frequent, especially so in the
case of young girls, who resort to drastic methods in order to
abort. Women who have children do this who feel they have
enough to do caring for those they have. They confide their
condition to some friend who very kindly tells them a means
to prevent bearing the child. Doctors do what they can to
stop this and I tell them the consequences of such things, but
unfortunately, there is no decrease. 77 A nurse from a far
western State finds, as she says, "all too many miscarriages.
The organizing of mothers meetings for young married women
in some of our rural communities and special instruction in
regard to the dangers of abortion seem to be an Important
step .... It seems fairly impossible to make a young
woman realize the seriousness and danger of inducing miscar-
riage."
A report by the Public Health and Marine Hospital Service
in 1912 on Sewage-Polluted Water Supplies in Relation to the
Study of Infant Mortality was based on a study of cities, where
it was stated that reduction in the general death rate is often
due to reduced death rate from diarrhea and enteritis that
depends on an improved water supply. There is no doubt but
that considerable gastro-intestinal disease of children in rural
areas, also is caused by had water, where wells and streams
are polluted. Such water is used in the milk, or given the
baby to drink. Where such conditions exist, it means that
the baby 7 s milk bottles are never properly cleaned, as is fre-
quently the case also, where there is no running water. Cloth-
ing washed in such water is brought in contact with the baby
and becomes a source of danger.
Milk in so many farming communities may be obtained fresh
once or twice a day, even though according to certain stand-
ards, it may be dangerous in other respects. The cost
of milk in small villages is often so expensive that it becomes
a luxury to poor families, who thus readily overlook the fact of
its being a necessity. One rural nurse mentions that she finds
milk very hard to obtain. Only a few cows are kept and the
milk is sold to neighbors but the demand for good milk
exceeds the supply.
The visiting nurse in many sections where midwives prevail
is able to discourage the practice of these, but even this course
78 NURSING PROBLEMS IN RURAL COMMUNITIES
is not .advisable where the doctors are untrained, and are the
sort who employ mid wives when their own babies are born.
Some of the nurses write of the worst calamities happening'
to pregnant women because of these doctors. The best the
nurse may do in such instances is to teach better methods and
impress upon all men and women the importance tof securing
graduate physicians and the best ones to be had, at such times.
A nurse in the southern highlands writes "The only attendant,
often, is the father or a neighbor. The idea prevails that any
woman who has given birth to a child knows enough to deliver
a normal case, or, as the people say : 'Ketch the baby/ which
explains their idea >of the service needed at such times. After
labor has commenced, they wait until the last moment before
sending for the doctor or midwife, who, if important or offi-
cious, will often say, the baby is turned wrong and will manip-
ulate the abdomen, knowing not a thing about anatomy or the
position of the baby. In this way, mothers and infants are
lost and yet such practices by the doctor are protected bv
law."
The practice of feeding babies everything they will eat
seems to be general. Before any teeth appear, babies often get
any solid foods they will take into their mouths, such as apple
cores and cabbage, the mother often masticating the food
before giving it to the baby. It may be a piece of salt pork,
bacon or green cucumber to suck, and in some rural sections,
many babies have been found playing with and sucking a
dirty piece of plug tobacco. Beer, coffee and tea are fre-
quently given. A rural nurse in a northern state writes :
"The tendency to give solid foods is prevalent. I find it done
in homes where you would naturally expect the mother to
know better. For example, I had to attend a baby eight
months old, having convulsions, and found that he had baked
beans and coffee for supper. This child's mother had been a
school teacher. Also, another case, a baby eleven months old,
had had boiled ham, cabbage and apple pie for supper. When
I spoke to the mother, she gaid he had had those same things
many a time and they had niot hurt him any.
When the baby is sick, the remedies used are sometimes tea
made from fennell or other herbs, soothing syrups, cordials,
vermifuges and whiskey. Paregoric and castoria are favorites.
In many rural sections patent medicines are used extensively.
Few rural nurses are doing prenatal visiting. This branch
of infant welfare work is one largely remaining to- be
developed by the rural nurse, and is one in which she may
find the cooperation of the doctors most helpful.
DISCUSSION 79
Superstitions 'are rampant in many of our rural districts,
but fortunately not all are affecting tlie health of the infant.
Their existence is, however, an index to the general need of
instruction as to what is right and best in the care and feed-
ing of babies.
Nursing problems left untouched, such as the maternal
nursing of infants, the overworked mother, and others, in many
instances are regional. Those dealt with here are more or less
common to rural nursing in general. The problems have been
stated, but little space given as to how they are to be met.
What the infant welfare workers are trying to do for the
city largely answers this question. Already we find the milk
station in the small community, an increasing number of
competent physicians and nurses, who are equipped by train-
ing and experience to help save the country babies, by sharing
in the improvement of general living conditions. More em-
phasis is being placed on rural hygiene better housing condi-
tions, the sanitary privy, the proper disposal of garbage and
more efficient health officers. These questions and more are
being agitated in our rural districts, until some day, added to
the advantages of the country over the city that already exist
as a place for rearing children, there will be others that so
vitally concern the mother and her child.
DISCUSSION
Mrs. E, E. Goodwin, Washington, D. C. : A good illustration
of what the development of nursing in rural communities and
small towns will do is available in the case of New Zealand,
a country about the size of the State of Colorado, with a
population comparable with that of Connecticut. The infant
death rate in New Zealand has long been regarded as the
lowest in the world, but the people were not satisfied and as
the result of this dissatisfaction about five years ago a society
was formed under the name of the Society for the Health of
Women and Children. The country was districted with a com-
mittee in each district. Approximately seventy of these com-
mittees are now active. Specially trained nurses are employed
and are called "Plunkett Nurses" in compliment to the wife
of the Governor-General who was much interested in the
work. The nurses act not as bedside nurses but as educators.
Each nurse is supposed to work within a radius of fifty miles.
Lectures on the care of babies are given and "living demonstra-
tions" are considered an important feature of the work. The
newspapers are extensively used to give publicity to the ef-
forts of the society and publish regularly a column called
80 NURSING PROBLEMS IN RURAL COMMUNITIES
U 0ur Babies" column. It is acknowledged that the efforts of
the society have resulted in a material reduction of the infant
death rate. Take as an example the case of the town of Dune-
din. In the seven years from 1900 to 1907 the average death
rate among children under one year of age was eight per one
hundred births. For the five years from 1907 to 1912 the aver-
age was six and one-half; for three years ending with 1912 the
average was six ; for the two years, five ; and for the year 1912,
four per one hundred births. The society is a private asso-
ciation, but it is subsidized and there is close supervision by
the Public Health Department.
Question: I would like to know what means are usually
taken by the rural nurse to get in touch with the needs in her
particular community.
Miss Clement : Some rural nurses have the privilege of visit-
ing the schools, either the county or local board of health or
board of education having granted permission for this, in some
instances appropriating an annual sum for such visiting. If
the nurse is not allowed in the schools for regular visits, she
finds other ways of learning to know the children in her com-
munity. She approaches them on the street, through various
clubs and classes, and at various meetings, as those of the
Boy Scouts or Campfire Girls.
Question: Is there a large percentage of women in the
country nursing their babies?
Miss Clement : It would be difficult to make a general state-
ment regarding this question. As far as we have been receiv-
ing reports, mothers in the southern highlands invariably nurse
their babies. As to other sections, from some communities,
the answer will be that all mothers nurse their babies, while
in others mothers do not because they think it is not necessary
that they should.
Question; How many nurses are there in rural districts?
Miss Clement: As far as recent investigations have shown,
there are approximately between 100 and 150. Under the Ked
Cross there are fifteen in almost as many different states. In
Virginia there are four. The number of public health nurses
in rural communities, especially east of the Mississippi, is
rapidly increasing.
DISCUSSION 81
The resolution just passed by this assembly will be of assist-
ance to the Bed Cross work. We need the nurse who has had
training and experience in public health nursing. We have
calls for nurses specially prepared for infant welfare work, or
for industrial nursing, even from the smaller communities.
Mrs. William lowell Putnam, Boston : The people of moder-
ate means who cannot afford the services of a trained nurse
need a trained attendant. Cannot our training schools for
nurses perhaps also train attendants to meet this need?
Miss Georgia Kevins, Washington, D. C. : This is a question,
it seems to me, that the training school is not yet prepared to
take up. I would like to know the number of women apply-
ing for rural nursing. Does it not take a peculiarly gifted
woman for that work?
Miss Clement: A considerable number of nurses have ap-
plied for the rural work. We have never been in a position to
refuse a community who wanted a nurse, and we have been
fortunate in getting nurses with considerable experience in
public health nursing to accept these positions. I agree with
Miss Nevins that it takes a woman of unusual ability and
peculiar character to do rural nursing. It calls for a special
type of woman. She should not feel that she is making a
sacrifice, but must go to the country because she prefers to
do so. It is a fact that the nurses who are in this work, as
a rule, would not be happy to return to the city as visiting
nurses.
Miss M. E. Lent, Baltimore: The Visiting Nurse Associa-
tion of Baltimore has at present eight nurses in the counties
of Maryland. Up to this time, it has been very difficult to get
nurses willing to isolate themselves from everything in the
way of medical and professional companionship. However,
we feel that the time is near at hand when the importance of
the nurse's work will be better understood by the country peo-
ple themselves, and the improved condition of transportation
will make it possible for her to take advantage of social work
and lectures in the near-by towns and cities, whereby she can
get advice and assistance that will fit her to meet the demands
of the people. She will feel that she is not cut off from op-
portunities for development in her profession, and I believe
we shall then not have much difficulty in getting good women
to do this work.
82 NURSING PROBLEMS IN RURAL COMMUNITIES
Dr. T. Wood Clarke, TJtica, N". Y. : In the development of
this rural nursing successfully it will be necessary to go
back to the training schools from which probably rural nurses
get their education. The nurse who will make the greatest
success in rural nursing is the native of the rural community
who understands the life and the people. Such girls, when
desirous of becoming nurses, usually go to the hospitals in
the smaller cities. These are generally small institutions, hav-
ing from twenty to forty nurses, conducted chiefly for surg-
ical purposes and usually completely dominated by the visit-
ing surgeon. In such hospitals the pediatric training gener-
ally consists in a few didactic lectures, and the nurse gradu-
ating therefrom hardly knows how to pick a baby up. If
under pressure from the State authorities a children's ward
is put in, a charge of from nine to fifteen dollars a week is
made for treatment, with the result that the beds are filled
with tonsilectomy and orthopedic cases, as the mother who
can afford to pay that amount for care of her baby suffering
from a medical disease will have a nurse and will care for
the baby at home. In order to obtain decently adequate
training in the care of children in a hospital it is essential
to have a properly equipped children's ward, with free beds.
The necessity of having the ward so endowed is a matter
which must be most forcibly impressed upon the minds of the
hospital managers. Pay beds are utterly worthless in train-
ing nurses in the care of babies. Until free children's beds
are placed in the small hospitals, rural nursing will have to
work against a great handicap.
Mrs. William Lowell Putnam, Boston: The Eobert Brigham
Hospital, in Boston, is undertaking to train attendants, but
this work is only about to begin, for the hospital is not yet
open.
Miss lent : I do not feel that training schools can under-
take the training of caretakers and attendants, but I do feel
that at present the State Associations of Graduate Nurses will
have to take this matter up. In Maryland last year, we or-
ganized classes in simple home nursing, hygiene, and sanita-
tion, with demonstrations, for over sixty women wanting the
course.
They are in no sense to take the place of trained nurses,
but we find them absolutely necessary in the homes where
simple care of chronic cases and relief, as well as some domes-
tic service is needed. The visiting nurses can supervise their
DISCUSSION 83
work in the homes of the poor and carry out important treat-
ments, etc., for which the attendants are not equipped.
Our greatest difficulty with them is to arouse a sense of
responsibility to the nurse who is supervising them, or to the
people for whom they are working. Their lack of training
makes them inaccurate and careless about hours and carrying
out directions. We had hoped to work out an arrangement
with the Home for Incurables, where young country women
who are not educationally equipped for training schools, could
have a course of eighteen months or so under the direction of
trained nurses. At the end of that time, they would be given
certificates as trained attendants. So far, we have not been
able to accomplish this.
The superintendents of training schools would be extremely
helpful in working out this plan. Of course, we all realize
that the lay people's point of view is most valuable. I, for
one, feel strongly that when a group of professional people
get together, they are apt to be a little narrow.
Miss Ahrens: Have you thought anything about training
attendants in connection with your Central Directory?
Miss Lent : The Central Directory of Maryland is under
the direction of the State Association of Graduate Nurses. It
was from this directory that the classes that I spoke of were
carried on last year. It was due to the enormous demand for
caretakers and attendants from the people of Baltimore, in-
cluding physicians and trained nurses, that we were obliged
to take on our list these untrained women, and for that rea-
son we feel that the graduate nurses should be responsible
for and help to make these attendants of more value and as-
sistance to the community by the lectures, classes and demon-
strations which were given them.
Graduate nurses all over the State have called for these at-
tendants to help out with their cases. Therefore, as they have
acknowledged the need for them, they should be ready to help
in the development of this piece of work.
Mrs. "William Lowell Putnam : In the Household Nursing As-
sociation (which is a Committee of the Women's Municipal
League of Boston) we have an advisory committee of hospital
superintendents, private physicians, directors of training
schools and others. We have three grades of workers, the
trained nurse, the trained attendant and the household helper.
As the work grows we establish new branches, but always
84 DISCUSSION
tinder the supervision of a trained nurse who is responsible
for every employe whether it be a trained nurse attending a
case of pneumonia or typhoid fever, a trained attendant or
a household helper. The trained nurse puts the right person
in the right house. We have done this for about a year, and
we are anxious to get in touch with managers of large con-
cerns to undertake the care of their employes for them. This
is in no sense a charity. All work must be paid for.
Rev. T. Hunter Boyd, Glasgow Scotland: I joined this As-
sociation four years ago as a Canadian pastor. The people
who are going to survive will be the people who live biological-
ly. This is my experience of ten years in a remote rural dis-
trict. While you are waiting to get this curriculum, such a
thing as the mothers' course arranged by the Department of
Home Economics at the New York State College of Agricul-
ture, at Ithaca, on household hygiene, makes a good ground-
work and an easy point of departure for some of these mat-
ters. Appeal must be made to these people through existing
agencies, often through the rural pastor and his wife, and in
ways that have no bearing on local needs. Avoid awakening
the bitter opposition that has been aroused by some scientific
workers who have been sent out to tell people how to do
things.
The Chairman: I will ask Miss La Forge to summarize our
thought.
Miss La Forge: The discussion is no doubt crystallized in
the appointment of the committee whose function is to assist
in standardizing the training of the public health nurse.
SESSION ON PEDIATRICS
Friday, November 14, 191S, 3.30 P. M.
COMMITTEE
CHAIRMAN
DR. HENRY F. HELMHOLZ, Chicago
DR. F. W. SCHLUTZ, Minneapolis
DR. HENRY L. K. SHAW, Albany
DR. J. W. SCHERESCHEWSKY, Washington
DR. EDWIN H. SCHORER, Kansas City
STATEMENT BY THE CHAIRMAN:
Following out the plan outlined by Dr. Gerstenberger last
year, it has seemed advisable to take up at this meeting a
number of neglected subjects that are of very vital importance
to the development of the medical side of the campaign against
high infant mortality.
Much can be done by the workers, who are actually doing
the work in infant welfare stations, to show the laity how
successfully babies can be fed on the very simplest of food
mixtures, but there are many physicians and laymen, who still
consider that infant feeding is so difficult that it is best left
to the mother, the nurse or the dealer in proprietary foods.
To show how much can be accomplished by the simplest means,
one of the papers will cover this subject.
The hygiene of infancy is a much-neglected field and one
that needs considerable revision. Until we have a large group
of teachers, however, it is rather difficult to enlighten the com-
munity. The teaching of the hygiene of infancy should be a
requirement in all medical schools.
Last year in the joint meeting of the Housing and Nursing
sections several papers were presented on the effect of heat
in infant mortality. These papers all represented work done
during the summer of 1912. The subject of the relationship of
heat to infant mortality is of such vital importance to the
development of more efficient work during the summer months
that it was decided to have the one referat of the meeting on
this very important subject.
85
SIMPLE MTLK DILUTION FEEDING
HERMAN SCHWARZ, M. D., New York
It seems a curious thing that in medicine, as in various
other branches of learning, when something new is proposed,
not necessarily meant to supplant, but only to add to
the known, the old is gradually discarded and the new
used exclusively. It has always seemed to me that if one of
us were to search through the old literature he would find
many excellent facts which are absolutely trustworthy, but
have gradually been forgotten. This has been especially evident
in infant feeding. From time immemorial up to, but not
including the present time, children have been fed upon sim-
ple mixtures of milk, water and sugar. Then the use of top
milk was introduced, erroneously thought by many to be the
essence of percentage feeding; the calculation by means of
calories was added to our knowledge by Reubner, Heubner
and Hoffman, and lo and behold, ordinary milk and water
with sugar was entirely forgotten. As I understand it from
our chairman, the main object of this paper is to make a
plea for the use of this ordinary milk, water and sugar feed-
ing, for it certainly could not be that I had to prove that
many children could be brought up on these simple dilutions
of milk. The social status of the infants whom we have to
feed may be divided into those seen in private practice, pre-
sumably of the wealthier classes, those in our institutions,
and out-patient departments.
Fortunately, this age is a great leveller and to a great
extent these two classes may be fed alike. I bring this up
because it makes me feel sorry for many of my patients in
private practice who have to go through elaborate procedures
consuming a great deal of time and trouble to prepare their
milk mixtures. The mothers, who are usually young and in-
experienced, puzzle and fret about the three ounces from the
top of one, and one ounce from the top of the other, and five
ounces from the top of the third, a bottle of milk added to a
certain amount of barley and limewater presumably to make up
86
HERMAN SCHWARZ, M. D. 87
a certain fat percentage that Is supposed to be the only thing
that the child will thrive on. Mind yon, I do not say nor do
I wish to be quoted as saying that I do not believe in top
milks in some cases, but I would like to emphasize the fact
that it is only fair to the mother, and in many cases to the
child, to try first the ordinary milk dilutions with the addi-
tion of sugar calorically sufficient.
Now, as regards our institutional classes and dispensary
cases. Here it is still more important not to make the feed-
ing of infants a terrifically difficult problem with the use of
a great deal of mathematics and apparatus. The addition
of limewater and of barley, unless indicated, the use of other
sugars besides the ordinary granulated or milk sugar is also
to be deprecated. The indiscriminate use of the malted sugars
and infant foods is in many instances unnecessary, adding to
the trouble of making the food, to the expense and to the time
consumed in preparing the same. In other words, unless there
is some indication one should try the ordinary dilutions of
milk, water and sugar in the greater percentage of our insti-
tutional patients. This plays a great role in our problem of
infant mortality. Simplicity and efficiency is the keynote.
Properly used, or even improperly used, they are less liable
to be dangerous than many of the cream mixtures and patent
foods. Nothing in infant feeding has seemed to me more
wasteful of time, energy and expense than the prescribing of
elaborate mixtures for purposes of weaning. In most instances
the simple dilutions with their relatively low fat and high
proteid content, are especially indicated and easily controlled.
In supplemental feeding also, without definite knowledge of
the amount of fat the infant is likely to receive from its
mother's milk, it is especially safe to give the ordinary dilu-
tions of milk and water.
I shall now proceed to tell you some of the results which
we have obtained both in private practice and in our insti-
tutional work by use of such simple dilutions. I have been
fortunate to be able to report to you the results in following
up thirty-six hundred children for the period of a year. Many
of these children are breast-fed until the eighth, ninth and
tenth month, some have had to have milk mixtures added to
or replaced entirely at a much earlier period. When the ad-
dition of cow's milk was indicated the ordinary dilution of
milk, boiled water and granulated sugar was almost always
used.
88
SIMPLE MILK DILUTION FEEDING
Of 1,182 infants thus fed and observed for a year the aver-
age weight at the end of the year was 19 pounds and 14
ounces :
TABL.E I
45 infants or, 3.7 per cent, weighed 13 to 15 pounds
129
116
197
185
173
143
97
40
57
1182
10.8
9.8
16.6
15.6
14.5
12.0
8.2
3.4
5.0
15 to 17
17 to 18
18 to 19
19 to 20
20 to 21
21 to 22
22 to 23
23 to 24
24 to 29
From Table I you will see that the greater number of our
infants were over 18 pounds (approximately 75 per cent).
And this in a material whose care could not absolutely be
controlled and whose resistance to diseases was so lowered
that a great many illnesses kept the weight back. Most of
these cases received additional nourishment to the ordinary
milk mixtures before the ninth month.
In Table II, I should like to call your attention to 160
bottle babies artificially fed from birth out of 3,600 clinic cases
per cent).
TABLE H
Average weight 8
12
" " 16.3
" " 17.2
20.8
pounds at one month
" " three months
'' "six months
'' " nine months
" " twelve months
These do not include infants with abnormally low birth
weight, premature or twins.
From the above it will be seen what results it is possible
to achieve with these simple dilutions and gives us time to
concentrate upon the cases that really need it for use of
mixtures such as top milk, malt soup and Eiweiss milk.
Similar or even better results are obtained on these simple
mixtures in private practice.
DISCUSSION 89
DISCUSSION
Dr, Godfrey R. Pisek, New York : I interpret this paper as show-
ing the tendency of today toward simplicity in infant feeding.
Dr. Schwarz has lost sight of, or at least has not emphasized,
one feature which makes the simplified dilution of water and
milk and sugar successful today. If ten or fifteen years ago
we had tried simple milk and water dilution, we would not
haye had the same good results, for now it is possible to obtain
wholesome milk in the majority of localities. Top milk mix-
tures were an improvement because doctors insisted upon good
certified milk in order to get their top milks. Today we get
good results with whole milk mixtures because bottled milk
is more universally used. In feeding a large number of infants
as in the milk stations of New York City, one year we tried
pasteurized milk at some stations and raw milk at others. At
the end of the year there was not much difference to be noted
in our results, the instruction given being the same. The
milk was handled under the direction of the nurses in the
homes. The next year a good raw milk alone was used, and
these simple modifications were efficacious and the records show
that we had good results. Simple dilutions will answer the
purpose of the average normal child ; but it should not be for-
gotten that in special cases we must adapt the modification
to the particular needs of the child.
Dr. L. Emmett Holt, New York: Early and continuous observ-
ation is the secret of success. Good results can be secured by
many different methods if only the children report regularly
once a week, and are kept under constant observation. The
difficulty is to secure regular attendance.
Dr. Julius Levy, Newark: I think Dr. Schwarz's paper is of
immense social value, because the average mother can be
taught this system of feeding at home. This saves an im-
mense amount of work and money for the doctors, nurses and
philanthropists ; but best of all it puts into the home the edu-
cational value of preparing the milk. When you have taught
the mother that, you have taught her all of personal cleanli-
ness and infant cleanliness. I think this association will do
an immense amount of good if it spreads the propaganda of
simple milk modification among the doctors as well as among
the mothers. The idea of feeding a child scientifically has
been associated with a very elaborate knowledge of calories
and percentages. If we can let every one know that simple
milk modification will meet the average case, we shall have
accomplished a great end.
90 DISCUSSION
The Chairman: A great deal can be accomplished by sim-
ple methods if they are rightly used. Dr. Holt advocated sim-
ple methods from the very beginning ; but simple methods may
not help out if we have an infant that has had all sorts of
mixtures fed to it before it came into our care. In our work
in cities where thousands of babies have to be fed, we must
have some simple procedure that can be taught the mother,
and the simpler, the greater the chance of success.
Mr. A, S. Trundle, Washington, D. C, : I would like to know
to what extent condensed and powdered milks are being used
for infant feeding in the country at large. Some years ago,
in 1903, 1 had occasion to call the attention of the local health
department to this subject, and made a request for an investi-
gation, which gave the following results :
FOOD SUPPLY OF 252 INFANTS WHO DIED FROM DIAEEHEAL DISEASES
BETWEEN JUNE 6 AND OCTOBER 10, 1903 (WASHINGTON, D. C.)
Character of Food No. Per cent
Breast fed 29 11.51
Artiflcally fed
Cow's milk (liquid) 94 37.30
Condensed milk 110 43.65
Proprietary food 5 1.98
Broths and soups 1 .40
Mixed feeding 13 5.16
Total 252 100
Notwithstanding this report (Annual Health Office, D. C.,
ending June 30, 1904), I find mention of the analysis of but
two samples of condensed milk in later reports (page 65, H. 0.,
ending June 30, 1912), though from five to seven thousand
samples of liquid milk were analyzed annually. I should like
some of the odium that has been so constantly levelled at the
milk and milk producers, to be removed and placed where it so
clearly, to my mind, belongs, on the preparations that are used
in the place of milk and to the manner and circumstances
under which they are administered.
TEACHING OF HYGIENE AND ITS RELATION TO THE
PREVENTION OF INFANT MORTALITY
I. A. ABT, M. IX, Chicago
As our experience has broadened and as the world- wide
interest has deepened in the study of infant morbidity and
mortality, it has been found that the causal factors are num-
erous and varied. Without going into detail concerning the
plans of investigation which have been pursued to bring to
light the evils which cause a high sick-rate and a high death-
rate, I desire to call attention to the possibilities which pre-
sent themselves to the medical profession in waging a more
effective warfare.
How can the medical profession yield more efficient service
in the prevention of infant mortality? Are our under-grad-
uate and post-graduate medical schools contributing their
share in instructing students in infant hygiene? Are infant
hospitals, medical societies and other institutions of instruc-
tion and learning contributing their share in the propaganda
of prevention?
It has seemed to me at times that our energy in this cam-
paign of prevention has been somewhat misdirected. It is true
that in opening a field so vast and so important many ave-
nues of attack must be attempted. The feeding problem, the
housing conditions, the prenatal influences, and many others
required study and plans for solution.
It was unavoidable that some errors should have occurred. It
is far from my purpose to discredit the valuable contributions
and the vast progress that has been made. I cannot fail to
recognize the far-reaching effects on the reduction of infant
mortality from the infant welfare stations and the efficient
service rendered by physicians and nurses in educating moth-
ers and saving infantile life. Nor would I discredit the cam-
paign of education which has extended into many homes and
brought light and relief into many dark places.
Every specialist in the treatment of infants' diseases comes
in contact with patients in hospitals and dispensaries, as
well as in private practice, where the babies show lack of
91
92 TEACHING OF HYGIENE
hygienic care, or such deviations from physiological living
that disease seems inevitable and normal development impos-
sible.
If we will take the pains to visit the registrar of vital
statistics during a hot day in mid-summer and look over with
him the certificates of deaths, we will find that the majority
of the certificates record the deaths of young infants, and if
we will read the names and locate the homes, we will find
that the little victims are in the vast majority of cases
of foreign birth and from the poorer quarters of the city.
Those of us who know the condition of these children dur-
ing their lives, know that the hygienic conditions which led
up to the sickness were bad, and the treatment during the ill-
ness was frequently inefficient and sometimes irrational. I
need refer only to the vast army of sick babies that succumb
to improper food or excessive food on the one hand or starva-
tion on the other; or those who are excessively physicked, or
possibly those who are weaned on medical advice because the
breast milk was supposed to be too rich or too poor.
During the early days of the infant welfare movement in
my own city, I attended a meeting in the City Hall, where
physicians from all parts of the municipality had come to-
gether in mass meeting to protest against the infantile
slaughter. Men of every rank came, and, we may assume,
prompted by every human motive. The discussion hinged upon
the shocking sick-rate and high death-rate, and the medical
men declared themselves as to the cause of the condition and
the best methods of prevention. Many words of wisdom were
spoken, but much more was said that reflected the inefficiency
and the inadequacy of medical knowledge pertaining to in-
fantile pathology and therapeutics.
As I sat and pondered, and listened to the speakers at this
mass meeting, to those who were ready to buckle on the
armor and unsheath the weapons with which they were going
abroad in the highways and the byways and the dark places
to wage holy warfare and to crusade against the demon of
disease and death and to educate the masses, I could not help
repeating again and again the refrain : "If you, my brethren,
will educate the masses, who will educate the educators?"
DISEASES WHICH LEAD TO INFANT MORTALITY
If one looks over the mortality statistics among infants
during the first two or three years of life, it becomes evident
at a glance that the highest mortality is due to gastro-intesti-
nal diseases, respiratory diseases, convulsions, whooping
I. A. ABT 3 M. D. 93
cough, measles, and sepsis among the new-born. Tuberculosis
plays some role in infantile mortality even during the first
years of life, though the occurrence of this disease is by far
more frequent in densely over-populated cities than in the
rural districts.
The accidents of birth furnish a small quota of infantile
deaths. Septic infections of the new-born still brings an ap-
preciable number to the sacrifice. We observe septic infec-
tions not only in private practice and among the poorer
classes, but also in hospitals of every degree. The two latter
groups must be considered under the class of preventable dis-
eases. That death occasionally occurs as an untoward ac-
cident in spite of great care is undeniable. That it frequently
occurs because of insufficient knowledge or care must be
conceded by everyone who is acquainted with the conditions.
STUDY OF NORMAL STANDARDS
Very brief references may be made in this connection to
the necessity of teaching the normal physiological standards
of infantile weight, measurements, length, the rate of growth,
and those elementary facts in the physiology and development
of infants upon which a better understanding of errors in
growth and morbid processes depend.
STUDIES IN HYGIENE
The number of booklets on the care and hygiene of the baby
is almost beyond calculation. They are for the most part
elementary in character and intended for the laity, and as a
rule are not sufficiently detailed in nature for the instruction
of physicians and medical students. In some medical schools,
students learn what little they know about hygiene of infants
from the teacher of obstetrics; and in a few schools the sub-
ject is taught by the department of pediatrics. I make bold
to say that in most schools the subject is taught indifferently,
if at all. I desire to take the position now that the subject
of infantile hygiene should be taught in the department of
pediatrics. It is my opinion that it should be a part of the
third year work. It should be a recitation course, and the
instruction should be given by one who is more than a mere
tyro in the department of children's diseases. The instruc-
tion should be based upon physiological knowledge,^ also util-
izing such facts in clinical pediatrics, in bacteriology and
pathology as pertain to the hygiene of infancy.
94 TEACHING OF HYGIENE
It is far from my purpose to enter into a discussion of
the elementary facts concerning the hygiene of infancy. There
is much to be learned at the bedside and in the department
of research concerning methods of procedure, and I believe
I am not in error when I say that some of our teaching and
practice in infantile hygiene is subject to extensive revision.
Nevertheless, there are well-grounded facts which may be con-
sidered fundamental and proved, and which may be accepted
in practice.
To enumerate very briefly, the course in infant hygiene
should consider the care of the infant during the first days of
life; the necessity for external warmth. The prevention of
infection in newly-born infants is a theme worthy of careful
study. The low resistance of the newly-born infant makes in-
fections possible. His anti-bodies are poorly developed; he
combats septic processes feebly and succumbs readily.
The technique of the bath, its temperature, the warmth
of the room and all other facts concerning its application are
as important from the physicians 7 standpoint as from that
of midwife, nurse or mother. The treatment of the cord, the
umbilical wound, the clothing, should be considered in detail
because they are matters of vital importance, simple when
understood, serious or frequently fatal when misunderstood.
The hygiene of food or feeding, the physiology of foods, the
advantages of breast feeding, are all considered in the larger
text-books on pediatrics and are easily accessible to every stu-
dent.
Air and exercise, the bathing of older children, the train-
ing of children, prevention of infections, and countless sub-
jects and questions will come up for consideration, and should
be treated in the greatest detail, because, after all, if medical
schools are educating men for general practice, these various
problems in infantile hygiene which require daily applica-
tion among normal and sick children are of the most far-
reaching importance. Indeed, one may go further and say
that adequate training of young physicians in infantile hy-
giene would be one of the most powerful forces in combating
infantile disease and mortality.
REACHING THE PRACTITIONERS
Medicine is subject to continuous changes. At times prog-
ress is swift. During the past twenty-five years a complete
revolution in medical knowledge has occurred. Physicians
are prepared, as a rule, for new teachings, though they must
DISCUSSION 95
be presented in popular or assimilable form. The general
practitioner is confronted with almost insurmountable dif-
ficulty. If he is to keep abreast of the progress in all branches
of medicine he will require an energy and industry that is al-
most superhuman. For this reason it is important that the
latest knowledge, from clinic and laboratory, should be pre-
sented in concise and somewhat popular form. To this end,
centers of medical learning should redouble their efforts.
A great organization like this society should be the stimulus
not only for the teaching of infantile hygiene in undergrad-
uate medical schools, but also for instruction to graduates in
medicine. The children's hospital should be a Mecca to which
practitioners should pilgrimage. Popular lectures should be de-
livered at these hospitals as well as at under-graduate and
post-graduate schools. Addresses should be delivered by com-
petent physicians before district and county medical societies,
so that the general practitioner of medicine might come into
possession of the latest and most accepted methods of pedia-
tric practice and particularly those facts which pertain to the
hygiene and prevention of disease among infants.
DISCUSSION
Dr. J. H. Mason Knox, Jr., of Baltimore : This is a very con-
cise and sensible presentation of the importance of teaching
elementary hygiene. Our medical schools give it much less
attention in their curricula than it deserves. Most of us who
are engaged in milk station work and in seeing many children
of the working classes, realize that a large part of our work is
made necessary simply because of the absence of the things
which Dr. Abt has advocated. Some of us look upon this
crusade as pointing to the time when this knowledge of the
hygiene of infancy will be more general. This knowledge of
the elements of infant hygiene should be a part of all teaching
of older girls in high schools and colleges. I look forward to
the time when no American girl shall graduate from a repu-
table high school or college, with a prospect of marrying and
having children and entering into that sacred relationship,
without this elemental knowledge of the care of her offspring.
I believe thoroughly that it is a legitimate part of every course
of normal education. Until we do have every American girl
and every foreign girl naturalized in this country possessed of
this knowledge, we must continue in this unsatisfactory way
of propaganda by societies of this kind, and by the very dis-
96 TEACHING OF HYGIENE
couraging attempts on part of nurses and doctors to tell
mothers who are beyond the age of learning easily, what mis-
takes they have already made in the care and feeding of their
children.
Dr. Helen C. Putnam, Providence: There is a large class ex-
cluded from Dr. Knox's remarks. He speaks of the graduates
from high schools and colleges, who are only a small fraction
of all the girls in the country. This society stands consist-
ently and strongly for educating the great mass of girls who
have no education at all during adolescence because their
parents do not care to have them go on. This society stands
for educating them in continuation schools under the regular
school department of the country. One of the greatest things
we can do in this society toward the prevention of infant mor-
tality is to have these continuation schools voluntary or com-
pulsory establish in every city in the country classes for
teaching girls who are past the elementary school education
how to take care of their children. We can go a step farther
and require not only health certificates for marriage, but cer-
tificates from father and mother of ability to care for a family.
A Member: I should like to go a step farther even than the
last speaker and suggest that the time to teach girls the care
of children is in the seventh and eighth grade grammar
schools. Many of these girls are already taking care of their
little brothers and sisters, and it is a question whether they
take care of them well or ill. At this age they are old enough
to acquire information which they can put to good use when
they become mothers.
Dr. S. Josephine Baker, of New York : This work is being
done largely throughout the country by the health boards, or
by private organizations in instances where the public author-
ities have not taken it up systematically. The time to teach
girls the care of babies is when they are in the elementary
schools and not to wait until the high school or college age is
reached. In New York we have our Little Mothers' Leagues
of girls from twelve to fourteen years of age who are taught
by lectures and practical demonstrations the principles of
baby care. Last year we had about 17,000 of these girls in our
leagues and the attendance is entirely voluntary. There can
be no question that at that age the information is more easily
absorbed; the children take it in without any self -conscious-
ness. They learn it as they do any other study and it stays
DISCUSSION 97
with them for the rest of their lives. We have girls as young
as ten years who are anxious to join our leagues. I believe
that boards of education should take up this training of girls
for motherhood as part of the public school course, and I be-
lieve, as people interested in the welfare of infants, we should
make it our business to conduct a campaign of education
among the educators themselves and lead them to see the
importance of the early training of young girls in infant care*
We can do nothing more important for the women of the future
than to teach them how to keep alive and well the children
they will bring into the world.
Question: I would ask Dr. Baker if she has had any trouble
from the Catholic Church, any objection?
Dr. Baker: Not at all.
Miss Marlatt: It seems to me this is wandering into the
discussion that we will have on Saturday evening in the ses-
sion on Continuation Schools. When we train a girl who is
from twelve to fourteen years old to take entire charge of the
younger children, I think we are putting too much responsi-
bility on her. The average girl of that age is not fit to take
care of a small child. She is not physically strong enough,
and her judgment is too immature. To teach her how to take
care of herself is all right, but to take care of other children
is going too far.
Dr. Baker: I agree with the former speaker that children
twelve to fourteen years of age should not be expected to take
care of babies. But they do take care of babies, and it is a
question of whether those babies shall be taken care of com-
fortably and decently or otherwise. John Spargo says that
the little mother is one of the greatest causes of infant mor-
tality. But if they must do it, we should teach them in such
a way that they can do it properly.
Dr. T. Wood Clarke, TTtiea, N. Y.: In educating the "Little
Mothers" to take care of their little brothers and sisters, Dr.
Baker is also educating them to take care of their own children
a few years later. She is starting in at the right place, and
is also getting to the mothers of the present day information
how to take care of their children. There is no better way to
reach the foreign mother than through her own children,
98 TEACHING OF HYGIENE
because the majority of the foreign mothers do not speak Eng-
lish and their children do. So this is much more than just
educating the little mothers, and I think this work is most
important
Miss Harriet E, leete, Cleveland: Our girls are being taught
by the school nurses in Cleveland. This work has been taken
up by the Babies' Dispensary after school hours. Children
like it very much. This year it will come under the direction
of the Board of Education.
HEAT AOT> INFANT MORTAMTY
By J. W. SCHERES CHEW SKY, Surgeon TJ. S. Pnfelle Health Service,
Hygienic Laboratory, Washington, D. C.
By far the most conspicuous phenomenon in connection with
the mortality of infants is the well known increase in the num-
ber of their deaths, which takes place in the summer months.
No incidence of death in any other age group seems to be so
immediately determined by meteorological conditions.
Hot summers produce an abnormally high infant death
rate and cool summers the reverse. For instance, Kruse ( 30 )
points out that the infant death rate in German cities of
over 15,000 inhabitants decreased from 190 in 1901 to 153
in 1910, a cool year. Yet, the universally hot summer (in
Europe) of 1911, was accompanied with a great rise in the
infant mortality, so that the infant death rate in these 'cities
for that year was 187, a rate not surpassed by any year sub-
sequent to 1901.
Again, Lief man and Lindemann ( BS ) state that the total
number of infants dying in Berlin in July and August, 1910,
was 1,439, while, in v the same months of 1911, 2,050 died, an
excess of 611.
The relation of heat to the summer deaths of infants has
naturally been the subject of much statistical inquiry. Forty
years ago, no doubt existed, in this country, at least, as to
the direct effect of heat in causing increased infant mortality
in the summer. The discoveries and developments in bacter-
iology and the etiology of infectious diseases, however, grad-
ually displaced heat into the background as a direct factor
in the deaths of infants, during the summer time. Until a
few years ago the general opinion has prevailed, while sum-
mer heat stood in causal relation to summer deaths, that this
relation was, by no means, immediate. Heat was regarded as
an agent calling other deleterious influences into action.
Recent observations, however, particularly those in Ger-
many of Finkelstein ( 9 ), Eietschel ( 54 > 55 > 56 > 57 ) ? Liefmann and
Lindemann ( 37 > 3S ), Klose ( 28 ), Kathe ( 25 )> and others have
reopened the question. We must now ask ourselves if sum-
mer heat is not, after all, by its direct action, the determinant
of a large part of the summer mortality of infants.
99
100 HEAT AND INFANT MORTALITY
It is to be regretted that the recent careful studies which
have been undertaken abroad have not been duplicated to any
great extent in this country and that it has been necessary
to derive most of the material for this paper from foreign
sources.
It has naturally been found impossible, within the limits of
this article to give complete treatment to the subject, but an
endeavor has been made to summarize the more important
observations.
RELATION OF THE SUMMER MORTALITY OF INFANTS TO* THE
TEMPERATURE CURVE
In the past, numerous comparisons have been made, and
many charts published, showing the relation of temperature
to infant deaths. Owing to the great prevalence, in the sum-
mer, of deaths from intestinal diseases in babies, such curves
have dealt mainly with the relation of temperature to deaths
from this cause. Moreover, the mean temperatures for weekly
or monthly periods have been the values taken with which to
compare the infant -deaths occurring in like periods.
The resulting curves are of a type familiar to us all. As
an example, let us look at Chart I from Fuerst. This chart
shows the monthly deaths of infants from gastro-intestinal
diseases in Munich from 1895 to 1904, as compared with the
mean monthly temperatures.
It will be seen that the death curve lags behind the tem-
perature curve, rising steeply to its apex in August and declin-
ing at a later period than the temperature curve, to reach 'the
winter norm in December.
It has been pointed out by Miller (* 3 ) in this country, so
far back as 1879, that we cannot make reliable deductions
from comparisons of this character. If we wish to study
the direct effect, if any, of heat upon infant mortality, we
must compare the daily deaths with the daily temperatures.
More recently this was pointed out by Prausnitz ( 52 ), Finkel-
stein, Willim ( 63 ), Liefmann and Lindemann and others. Wil-
lim and Finkelstein seem to have been the first to publish such
curves, but the most careful study of this nature in recent
literature is that of Liefmann and Lindemann, 1 which deals
with the relations of heat to infant mortality in Berlin for a
period of 15 years.
NOTE 1. (A careful study of Liefmann and Lindemann's work is recommended,
as well as of Rietschel's comprehensive monograph on this subject. I am in-
debted to these authors for much of my material.)
J. W. SCHEEESCHBWSKY, M. D.
101
CHART I
MONTHLY INFANT DEATHS FROM INTESTINAL DISEASES
IN
3300*79
JAN.
FEB.
MAR.
APR.
MAY
JUNE
JULY
AUG.
SEPT
OCT
NOV
30<KM7
^^
^MM^
2700+15
/
"I
\
\
\
2400+13
/
/
\
A
2100+11
/
/
\ ^
\
1800+9
/
/
\
\
\
1500+ r
/
/
\
1200+ 5
/
*
\\
900+3
'^
/
\
\
\
v^
600+I
\
\
300-1
X
/
\
\
"({trr Rinwttt.) mmm U.S. Puftuc HEALTH SCKVICC ^ <.***.
TEMPERATURE DEATHS
Let us now examine one of Liefmann and Lindemann's
charts (Chart II) which shows the relation of the daily infant
deaths to the daily temperatures, in Berlin, during the year
1905, which was characterized by some hot weather for that
latitude.
According to these authors, in the spring of that year, the
daily infant deaths were between 15 and 20, Had this rate
been kept up throughout the year some 7,000 babies would
have died. As a matter of fact, there were about 10,000
deaths of infants, the excess being almost entirely due to in-
creased mortality in the summer. On 'certain days the mor-
tality was so high that it was two or three times the norm.
102
HEAT AND INFANT MORTALITY
J. W. SCHERESCHEWSKY, M. D. 103
An examination of this chart -shows two striking peculiar-
ities. First, two sharp prominences with their apices on the
7th of June and the 2d of July, respectively; and, second,
a high and broad elevation in August, crowned with a suc-
cession of smaller secondary prominences.
Liefmann and Lindemann distinguish two elements in their
curves, (a), the early summer mortality and, (b) ? the late
summer mortality,
Early summer mortality. On inspection it is seen that
there is a striking parallelism between the temperature curve
and the mortality. This is especially manifest in the sharp
increase in the number of deaths on June 30th and July 1st,
accompanying the high temperature on those dates.
This parallelism is manifest, not only on the hottest days,
but the moderate heat of the fourth and fifth of June, also, is
sufficient to provoke an increase in the deaths recorded.
An interesting circumstance developed from the study of
this and other curves in their series is, that generally speak-
ing, at first, only temperatures of considerable height (22 to
25 0.) are effective in provoking an increase in the infant
deaths. Often the first hot wave does not call forth the
expected response.
The late summer mortality. The late summer mortality cor-
responds to the high and broad curve of deaths from the mid-
dle of or end of July to the last of September. This portion
of the chart presents a different relation to temperature than
that corresponding to the early summer. The high mortality
present in the first part of August no longer recedes to the
norm with falling temperature. On the contrary, it remains
great in spite of the interpolation of periods of cool weather
of some duration. Nevertheless, rises in the temperature pro-
voke an increase in the number of deaths which serves to give
this curve its jagged outline.
The mortality curve, in this portion of the summer, seems
to express the summation of the effects of a long period of
warm weather, as a basis, combined with the exacerbations
provoked by repeated sudden increases in the temperature.
Curves of a cool year. If now we examine these curves for
a cool year we find a different set of relations. Chart III.
shows these conditions during the year 1907, a cool summer
with only one hot period in May.
104
HEAT AND INFANT MORTALITY
CO
irm LJ 3SHn SJLWHHI jo
J. W. SCHERESCHEWSKY, M. . 105
We see, upon examination, a response to the hot weather
of the 7th and 12th of May, but, owing to the very moderate
temperatures prevailing through out the rest of the year, the
hroad mid-summer rise in the mortality curve Is practically
absent.
CHARACTER OF DEATHS IN THE EARLY AND LATE SUMMER
The differences in the reactions of the mortality curve to
temperature, in the early and the late summer, is accompanied
by differences in the nature of the infant deaths recorded. Ac-
cording to Liefmann and Lindemann, an examination of the
death certificates showed that, in the early summer a large
number of deaths were recorded with acute symptoms, not
referable to the intestinal tract.
For instance, of the 88 infants dying on the hot day of
.July 2, 1905, only 16 died of intestinal diseases, while in 52,
or about 60 per cent, the cause of death was given as con-
vulsions, brain stroke and heart failure, or, in other words,
with symptoms mainly referable to the central nervous system.
As the summer progressed, however, the number of deaths
from gastro-intestlnal diseases gradually increased, so that,
towards the end of August and the beginning of September,
from 72 to 78 per cent of the diagnoses on the death certifi-
cates gave this class of diseases as the cause of death. Hot
days brought an increased number of certificates recording
deaths with acute symptoms, and a number of such deaths
were found, even in comparatively cool weather, at this period.
A considerable difference in the duration of illness was ap-
parent. In the early part of the summer about 50 per cent
of the infants died after an illness lasting only one or two
days, while in the latter part only about 20 per cent died with
such acute symptoms. The remainder succumbed to illness
of a more chronic character.
The following tables from Liefmann and Lindemann give a
good idea of the relative frequency of deaths with acute symp-
toms and from gastro-intestinal diseases' in the various parts
of the summer (Table I.) and the course of the mortality from
gastro-intestinal diseases during the summer of 1905 in Berlin
(Table II.)
106
HEAT AND INFANT MORTALITY
TABLE I
Number
of infants dying
each day
Berlin, 1905
In the
cool part of
early summer
In the
hot part of
early summer
In the cool part
of late summer
with high
mortality
Gastro-intestinal diseases.
Congenital debility and at-
roDhv
3.0
6.0
13.2
6.2
41.3
43
Other affections
12.6
43.7
25.3
21.6
63.1
70.9
Convulsions, brain stroke,
and heart failure
7.7
32.7
20
TABLE II WEEKLY DEATHS FROM GASTRO-INTESTINAL DISEASE,
IN BERLIN, DURING THE SUMMER OP 1905
(After Liefmann and Lindemann)
1905
Total Infant
deaths
Deaths from gastro-inte-
tinal diseases
Number
Per cent
1. Cool part of early summer,
(May 14-20)
171
228
125
315
441
498
317
168
25
66
41
148
306
389
250
67
14.5
29
33
47
69
79
72
39
2. Hot part of early summer,
(June 4-10)
3. Cool part of early summer,
(June 11-17)
4. Hot part of early summer,
(July 2-8)
5. Hot part of late summer,
(July 30-Aug. 5)
6. Cool part of late summer,
(Aug. 13-20)
7. Cool part of late summer,
(Aug. 27-Sept. 2)
8. Cool part of year after decrease
in mortality (October 1-7) . . .
J. W. SCHERESCHEWSKY, M. D. 107
We see from the foregoing that the march of infant mortal-
ity in the first part of the snmmer is characterized by the
great number of deaths with acute symptoms and short dura-
tion (24 to 48 hours) while, later, the high ; broad and slowly
descending curve is largely produced by the deaths of infants
who succumb to more or less sub-acute affections, mainly, of
the gastro-intestinal tract.
The influence of heat upon the mortality of infants in the
first part of the summer is apparently immediate. In the lat-
ter part of the summer this no longer seems to be the case.
At first sight one would be inclined to state that, while some
causal relation is manifest, the late summer mortality of in-
fants is not directly influenced by the heat which, therefore,
can stand in no immediate relation to this phenomenon.
A closer examination, however, shows that we can, by no
means, suppose that infants are necessarily relieved from the
action of heat by reason of the comparatively long remissions
of the temperature in the latter part of the summer. If we
are to examine the effects of heat upon infants we cannot
arrive at conclusions by considering outdoor temperatures only.
The nursling passes most of his time indoors and it is the
indoor meteorological conditions to which he is mainly sub
jected.
INDOOR TEMPERATURES
The credit of calling attention to the importance of in-
door temperatures belongs to Fliigge ( lx ) who, in 1879, pub-
lished a series of observations upon in-door temperatures in
mid-summer. He found that the temperature, in-doors, was
dependent upon the degree of heat received by the walls from
the sun.
The diffusion of the heat through the walls was found to be
relatively slow, so that their inner surfaces reached their
maximum temperatures in the following order: East wall,
9 P. M.; south wall, 12 M.; west wall, 3 A. M.
The effect of radiation of heat from the inner surfaces of
walls, protracted far into the night, was to maintain the
in-door temperature at a level considerably in excess of that
of the external air. During a relatively cool summer Fliigge
found that the mean in-door temperature might exceed the
exterior by as much as 9.50. (17.1 F.)
Other observations on the in-door temperature have been
made by Meinert ( 41 42 ), Hammerl ( 16 ), and Bietschel ( 5S ), in
Germany; in this country by Chapin ( 2 ), Knox ( 29 ), and
Helmholz ( 19 ).
108 HEAT AND INFANT MORTALITY
Meinert ( 41j * 2 ) observed an average excess of 8.9 0. (16 F.)
of the in-door oyer the out-door temperature in a room in Dres-
den in which an infant had died of summer diarrhea.
Hammerl ( 16 ) made observations in the dwellings of work-
men and found that the average mean in-door temperatures
were greatly in excess of the out-door. In one instance the
temperature never fell below 24 C. (75.2 F.) for a period of
over 14 days and often rose to 32 C. (89.6 F.) and, on one
occasion to 35 C. (95 F.) with out-door temperatures that
never exceeded a maximum of 23.7 C. (74.6 F.).
In the cool summer, of 1910, Eietschel ( 55 ) made observa-
tions with maximum and minimum thermometers and record-
ing thermographs in dwellings in Dresden, in which, for the
past five years, a high infant mortality had been recorded.
He states: "I admit frankly that the results astonished
me. I had indeed supposed, that, in such dwellings, tempera-
tures of considerable height might prevail in summer, but I
had never expected that such excessive temperatures could
be maintained, not only daily but weekly, with an out-door
temperature relatively so low."
In some instances the temperatures rose to 35 C. (95 F.),
and 37 C. (98.6 F.) with out-door maximums of but 23.5 C.
and 21 0. (74.3 F. and 69.8 F.). During the hot summer
of 1911, he reports an instance in the home of a workman, of
maximum temperatures of 38 0. (100.4 F.) with minimum of
30 C. (86 F.).
Similar measurements have been made in this country by
Chapin ( 4 ), Knox ( 29 ), and Helmholz ( 19 ), during the sum-
mer of 1912 with like results. Helmholz observed, in the
stock yards district of Chicago, maximum in-door tempera-
tures 30 F. in excess of the out-door maximum. Minimum
temperatures below 80 F. were rather infrequent, occurring
only 83 times out of 1,374 maximum and minimum readings.
It is clear, from the foregoing, that infants are often
obliged to endure, for considerable periods, temperatures
which are greatly in excess of those of the external air. More-
over, the effect of these temperatures is often enhanced by
excessive clothing and rubber diapers. It is a too frequent
experience to find, in crowded tenement homes, the busy mother
keeping the baby in the kitchen, often near the stove, in
order to have it close at hand.
EFFECTS OF HUMIDITY
The influence of a high degree of moisture in the air in
increasing the effects of heat is well known. It would natur-
J. W. SCHERESCHEWSKY, M. D. 109
ally be expected that hot days with high humidity would
show the greatest increase in infant death. The observations
on this point are inconclusive. Days on which great infant
mortality has been recorded, have, for the most part, been hot
and dry.
Meinert, Prausnitz ( 52 ), Liefmann and Lindemann and oth-
ers point out that the relative humidity of the external air is,
by no means, an index of the moisture to which infants are
exposed. In the dwellings of the poor, where the great
majority of infant deaths take place, the infant passes a large
part of his time in narrow and usually crowded quarters,
where the relative humidity may be greatly raised by the lack
of ventilation, the moisture derived from the breath and skin
of numerous inmates (frequently five or six in a single room),
and the water evaporated in cooking, ironing and washing.
Indeed, Kubly's ( 31 ) observation (cited by Meinert) showed,
that in the dwellings of the poor in Dorpat, a mean relative
humidity of 83 per cent was formed in 228 observations and,
in 30 instances 90 to 98 per cent was recorded. Knox's observ-
ations in Baltimore, during the summer of 1912, showed the
relative humidity in such dwellings to vary between 70 and
80 per cent.
CIRCULATION OF AIR
It is evident that the circulation of the air is of great
assistance in eliminating heat from the body, by accelerating
evaporation. I will cite only the recent experiments of
Fliigge ( 1S ) and his co-workers, Paul, Ercklentz and Hey-
mann. They showed that in stagnant air, symptoms ' of heat
retention begin to make their appearance at temperatures of
24 to 25 C. (75.2 F. to 77 F.), which, however, disappeared
when the air was set in motion by a fan.
If, then, heat is to be regarded as a direct factor in the
causation of summer infant mortality, we would expect to
find an increased number of deaths of infants in houses and
in sections of cities where conditions are unfavorable to the
circulation of air. Such, we find is the case.
JBallard (*), in his extensive investigations of summer mor-
tality in England, noted that when the wind had free access
to houses the summer infant mortality was low, while it was
high in those cities, or sections of cities, where, from the dis-
position of the streets or houses, they could not be swept by
the prevailing winds in summer.
Meinert ( 41 42 ) to whom belongs the credit of being the
first to investigate, in Dresden, the relation of housing condi-
110 HEAT AND INFANT MORTALITY
tions to the summer mortality of infants found, that in prac-
tically every instance, in the case of 580 infants dying in the
eleven summer weeks of 1886, the conditions were such as to
prevent the free circulation of air in the rooms in which these
children lived. In only one instance did any of these infants
die in a house, exposed freely on all sides to the wind. The
infants died in those dwellings, which from their low-lying
situation, their location in the rear of other dwellings, the
presence of courts, narrow streets and shut-in architecture,
were denied the access of cooling hreezes; or, from the dispo-
sition of the windows, through ventilation was impossible.
Thus on low-lying Hechtstrasse, with shut-in houses and
many courts, 18.49 per cent of the living children under one
year died; on high-lying Kiefernstrasse, with a more open
style of architecture, only 2% per cent; upon Johan Meyer
Strasse, with model workmen's homes, open to the air on all
sides, none.
Prausnitz points out that in the absence of through ventila-
tion, the only exchanges which can take place between the
inside and the outside air arise through differences in their
temperatures.
In the absence of through ventilation these differences of
temperature are so slight, in hot weather, that stagnation
readily takes place. He and his co-workers ( 18 ) investigated
in Graz the location of windows in dwellings in which infants
had died of summer diarrhea during the years 1898, 1903
and 1904. A dwelling was regarded as susceptible of through
ventilation when it possessed windows in opposite walls, as
partially so when the windows were in walls at right angles
to each other, and as not susceptible, when windows in one
wall only were found.
They obtained the following results :
Year
Susceptible of
through ventilation
Partially susceptible
of through ventilation
Not susceptible of
through ventilation
1903, 1904
1898
27.4%
15.4%
7.1%
19.5%
65.5%
65 %
It will be seen from the above that in the years 1903 and
1904 approximately 80 per cent of these dwellings did not
present conditions favorable to a free circulation of air.
J. W. SCHERESCHEWSKY, M. D. Ill
OTHER HOUSING CONDITIONS
Besides Meinert's former work, other careful studies of hous-
ing conditions in relation to infant mortality have been made.
Among these may be especially mentioned those of Willim ( 63 )
in Breslau, of Liefmann ( S4 ) and Kathe ( 25 ) in Halle, and
Liefmann and Lindemann ( 3S ) in Berlin. These investiga-
tions all bear testimony to the great influence housing condi-
tions have upon infant mortality, and particularly the condi-
tions favoring high in-door temperatures or absence of free
circulation of air.
While it is true that the conditions were such as would
favor, as well, the dissemination of infectious disease, we
encounter the paradox that certain conditions, intrinsically
unhygienic, have a distinctly favorable influence on the sum-
mer mortality of infants.
Thus it was found by Meinert, Willim and Liefmann and
Lindemann that infants living in basements and cellars show
a smaller increase in their summer death rates than do breast-
fed infants ; while, with respect to the other stories, the death
rate usually increases as we go up, being "found highest next
to the roof. (Meinert found the greatest number of deaths
in the ground and first floor.)
Liefmann's and Kathe's investigations in Halle showed that
the summer mortality of infants was rife, not only in certain
streets, but in certain houses. Thus Liefmann found that out
of 380 streets which Halle possessed at that time, no less than
141, or over 37 per cent, had no infant deaths.
We can also readily conceive from the character and situa-
tion of the houses in which infants die that, once they are heated
through by the warmth of the early summer, the heat stored
in the earth, pavements, and walls, in their shut-in location,
prevents any substantial cooling off in the late summer, in
spite of periods of moderately cool weather. In the early sum-
mer, before there is much stored heat, remissions in the exter-
nal temperature have a much greater effect.
EFFECTS OF HEAT IN CAUSING DEATH
It must be clear, from the foregoing, that the greater the
summer heat the greater the number of infant deaths, and
that it is an in-door and not an out-door climate to which
infants are exposed. There remains for discussion the man-
ner in which their deaths ensue. There are two hypotheses
by which these can be explained.
112 HEAT AND INFANT MORTALITY
Owing to the fact that the great majority of infants dying
in the summer are bottle-fed, the deduction is logical that
the onus of their deaths must be placed largely upon the food
most generally used in the artificial feeding of infants, namely,
cow's milk, which becomes so readily spoiled by the summer
heat, when carelessly produced and handled.
We find two views generally held to explain the pernicious
action of cow's milk in the summer:
1. That as a result of careless handling and inadequate
cooling on the part of the producer and the consumer, the
germs which always contaminate cow's milk undergo such pro-
liferation that the ordinary saprophytic bacteria in milk, or
their toxic products, endanger the life of the artificially fed
infant.
2. That the deaths of artificially fed infants are not due,
solely to the use of a germ-laden milk and their resulting
poisons, but that the use of an alien food creates a pre-
disposition to infection with pathogenic bacteria which may
be acquired in other ways than through the milk, as for
example, through contact or by the agency of flies.
3. A second hypothesis, held in this country some thirty-
five years ago, and advanced anew by Meinert, in 1881, is
that heat itself, by its various effects upon the infant organism
must be regarded as the chief factor in the summer mortality
of infants. This theory has recently gained many adherents
abroad, such as Eietschel, Finkelstein, Liefmann and Linde-
mann, Kathe, Klose, Prausnitz and others.
I will endeavor to discuss, as briefly as possible, these hypo-
theses.
Effects of stale, or germ-laden milk. Milk is so plentifully
seeded, during the course of its production and handling, with
germs of all kinds, their multiplication is so favored by tem-
peratures in excess of 60 F. and the possibilities of trans-
mitting disease through its use are so obvious, that none can
deny its agency in this respect. Indeed, the accumulating
literature of the epidemics of typhoid fever, the paratyphoid
affections, diphtheria, scarlet fever and septic sore throat
transmitted through the agency of milk, not to mention the
frequent presence of the tubercle bacillus in milk and milk
products, only serves to emphasize the necessity of rigidly con-
trolling the production and handling of this great source of
food.
The most extensive investigation of recent years as to the
effects of feeding different kinds of milk to infants is that
of Park and Holt ( 49 ) in New York. Six groups of infants
J. W. SCHERESCHEWSKY, M. D. 113
were observed, respectively fed on: cheap store milk, con-
densed milk, milk from a central distributing station, good
bottle milk, the best bottled milk and breast milk.
During the winter but little differences in the results were
noted, no matter what milk was fed. During the summer,
however, the difference was striking. The infants fed on
breast milk and the best bottled milk showed the best re-
sults, while those were very bad in the case of the infants fed
on condensed milk and the cheap store milk.
Eietschel, Liefmann and Lindemann and others, however,
advance the following reasons to show that the influence of
cow's milk in causing summer infant mortality has been over-
estimated :
1. The hypothesis that the ordinary saprophytic germs of
milk produce disease and death in infants is singularly lack-
ing in experimental confirmation. The most exhaustive and
complete experiments of this kind, i. e., those of Fliigge ( 12 ) ?
show that of the saprophytic, at most, only the peptonizing
bacteria in milk may have some harmful action and are capa-
ble of exciting diarrhea when fed to dogs in large quantities.
2. Milk epidemics reported, in the literature, are mass
epidemics like other food epidemics. All the individuals, ir-
respective of age, who took the milk, were affected. Their
course has also been quite different from that of the summer
diarrhea of infants.
3. The use of sterilized milk ought to have a very great
influence in reducing summer infant mortality. This does
not seem to be the case. For instance, Liefmann ( 34 ) reports
that infants boarded out in Halle have been provided since
1904 with sterilized milk by the municipality, yet the summer
mortality among them from gastro-intestinal disease has been
the same or somewhat greater than that prevailing for the
rest of the city infants. Out of 384 infants supplied in this
way during 1905, 1906 and 1907, 45, or about 12 per cent, died,
of which number 30, or 8 per cent, died of intestinal diseases.
Moreover, it has been a common clinical experience to see in-
fants who have received nothing but the purest cow's milk,
from a bacteriological standpoint, sicken with all the symp-
toms of typical summer diarrhea.
4. The increase in the summer mortality of infants seems
to be initiated only by temperatures in excess of 24 G. "While
it is true that multiplication of germs in milk is greater at
30 C. than 24 0., it cannot really be maintained that milk
will not spoil almost as effectively at the latter tempera-
ture than at the former. Yet why should milk, spoiled at
114 HEAT AND INFANT MORTALITY
24 0. not increase mortality, while milk spoiled at 30 does?
5. Finkelstein ( 9 ) and Liefmann and Lindemann ( 37 ) point
out that on hot days a large part of the mortality ensues
within 24 to 48 hours. Liefmann and Lindemann state, in
this connection: "It is difficult to conceive how the spoiling
of the milk, the infection or the intoxication of the child, the
sickening and, finally, the death can be compressed all within
a single day."
While it is true, in the case of the investigation of Park
and Holt ( 49 ), that the infants who received the cheap store
milk showed the worst feeding results, there are certain cir-
cumstances, noted by the investigators, which must be taken
into account in weighing the conclusions.
For instance, the results of feeding with condensed milk,
in which the bacteria were found to be relatively few, gave
results but very little better than that obtained with the
cheap store milk. Again, we are told that the store milk was
boiled and subsequently kept on ice in the majority of in-
stances. The results of the laboratory examination of num-
erous strains of bacteria isolated from the milk showed only
one strain that produced diarrhea when fed to kittens.
The environment of the children was not the same, those
using the store milk belonging to a poorer and needier class.
It is just this class of the population who crowd into small
quarters with windows opening on courtyards and light wells.
Moreover, the investigators themselves state: "There seem
to be many factors, but a consideration of the facts accumu-
lated indicate that heat is the primary factor and bacteria
and their products a secondary one, except when the contam-
ination is extreme or the pathogenic organisms present." And
again : "The depressing effects of great atmospheric heat, i. e.,
a temperature of 90 F., or over, were very marked in all
infants no matter what their food. Those who were ill were
almost invariably made worse and many who were previously
well became ill." They also indicate that proper care was
after all the most important factor in keeping the infants
well. With proper care some infants were fed successfully
all summer on the cheap store milk.
That stale milk is not always deleterious to infants when
the environment and care are good is shown by Eietschel's ( 54 )
experiments. Kietschel, after experimenting upon himself, fed
to a series of infants cheap store milk which had previously
been heated (as is the universal custom in Germany) and then
allowed to stand in an open vessel for 24 hours at room
temperature in the summer. The infants for the most part
J. W. SCHERESCHEWSKY, M. D. 115
did very well on this diet and showed not the slightest trace
of disturbance. In a few instances, he had the impression
that such a milk could cause more readily loose stools than a
milk poor in bacteria. The milk was often turned when fed
to the infants.
One further point which must be noted is that the infants
which show the least increase in their death rate in sum-
mer are not the breast-fed infants, but infants who live in
basements and cellars. Thus Liefmann and Lindemann in-
form us that in the cool part of the early summer in Berlin
breast-fed infants died at the rate of 1.5 per day, while in
the hot part of the summer the rate was 4.5. The cellar
infants died at the rate of .9 per day in cool weather and
2.25 per day in hot weather. Thus the death rate of the
breast-fed children was increased three-fold by the hot weather
while that of the basement infants was only 2% as great.
This can only be explained by reason of the greater coolness
of cellars and basements.
Again in the hot month of August in 1911 in Berlin, the
breast-fed infants showed twice the mortality they did in the
cool part of the summer, 107 dying in August as against 51
in June.
While it cannot be denied that milk, so long as it is ex-
posed to contamination by human hands and flies, or is ob-
tained from cows with tuberculosis or with inflammatory dis-
eases of the udder, must ever be liable to convey pathogenic
germs, it would seem, in view of the foregoing, that those
who would attribute the bulk of the summer mortality of
infants to stale milk, take a too one-sided view of the matter,
and one not borne out by the facts.
The role of infections in the summer mortality of infants.
The summer diarrhea of infants has presented so many of the
appearances, at first sight, of a specific infectious disease,
as, for example, its restriction to certain streets or sections
of a city and the almost explosive rise of the mortality, that
much labor has been expended to discover a specific organism.
The bacteriology of summer diarrhea was first carefully
studied by Escherich ( 8 ) in Europe and Booker ( s ) in this
country. They found no definite organism associated with
summer diarrhea. In 1902 and 1903, Flexner ( 10 ), Duval and
Bassett ( 6 ), Wollstein ( 66 ), Waite ( 62 ), Kendall ( 26 ), and
others, reported the finding of the bacillus dysenteriae
(Flexner type) in the stools of numerous infants suffering
from diarrhea. It should be noted, however, that, in the
116 HEAT AND INFANT MORTALITY
great majority of these cases the dejections were typically
dysenteric with blood and mucus in the stools.
Within the last few years Morgan ( 44 ) and his co-workers
report the isolation of a motile, glucose-fermenting organism,
which does not attack lactose or mannit from the stools of
infants suffering from diarrhea in London during the years
1904-1906. The organism was present in about 45 per cent of
the cases examined and produced diarrhea when fed to labor-
atory animals.
There is therefore evidence that a fair proportion of the
deaths of children in summer are due to specific infections,
but the evidence adduced is not sufficient to explain all of
them in this way. Moreover, Liefmann and Lindemann have
studied the course of other epidemics, such as cholera epid-
emics in Berlin in the summer time in order to throw some
light on this matter. They found that no effect ascribable
to temperature was visible in the course of such epidemics, as
their progress was quite uninfluenced by meteorological con*
ditions, the curves exhibiting a remarkable contrast to the
infant mortality curves in the same city.
Again, McLaughlin ( 39 ) has shown that where a definite
source of infection for gastro-intestinal diseases exists, as, for
instance, a polluted water supply, the death rate in infants
from enteritis may be almost as great in the spring as in sum-
mer months. This has been especially true of localities which
have rather cool summers.
Flies. Any hypothesis considering the summer deaths of
infants as due to infections must clearly consider flies as
probable or even principal carriers of the infecting organisms.
The fly theory has been very carefully considered by O. H.
Peters ( B0 ), who made an intensive study of the incidence of
diarrhea in two sections, inhabited by workmen, of the city
of Mansfield, England. He found no direct proof of the
agency of flies in carrying summer diarrhea and states that
before this theory can be confirmed, experiments of scientific
accuracy will be required, such as were used to prove the
transmission of yellow fever and malaria by mosquitoes. On
the other hand, he could develop no data which would render
the implication of flies in the transmission of gastro-enteritis
inherently impossible.
The following chart drawn from the data given by Mven ( 48 )
shows the incidence of flies as compared with the deaths from
summer diarrhea in Manchester, England, by weeks. The
incidence of flies was determined by counting the numbers
caught weekly in traps located in various parts of the city.
J. W. SCHERESCHEWSKYj M. D.
CHART IV.
117
WEEKIY DEATHS FKOH SUMMER DIARRHEA
118 HEAT AND INFANT MORTALITY
It will be seen that the death rate in infants lags behind
the fly curve and then increases at a much more rapid rate
than the flies. These increase in arithmetical progression
while the increase in infant deaths from diarrhea is almost
geometrical. The impression derived from this curve is that
of an increase in flies and summer diarrhea both due to a
common cause.
One other difficulty is the circumstance that Peters found,
while 32 per cent of the breast-fed infants investigated de-
veloped an attack of diarrhea during their first year, that 90
per cent of the infants on cow's milk were affected. Yet it is
difficult to conceive of an affection, spread by flies, being selec-
tive in its nature in the same age group, especially as Peters
found the proportion of breast-fed and bottle-fed children
receiving table food to be approximately the same.
Besides this Peters found that the difference in the inci-
dence noted above was dependent, not upon cow's milk, per se,
but upon the circumstance of being breast-fed or not breast-
fed. It cannot be denied, however, that cow's milk, when
kept uncovered in the home is much exposed to infection by
flies.
Finally, Peters found that certain areas investigated had
a much higher incidence of diarrhea than other sections show-
ing a much greater prevalence of flies.
EFFECTS OF HEAT UPON INFANTS
There remains now to examine the ways in which heat
might damage the organism of the infant.
Heat stroke In infants. We are all well aware that, every
summer, numerous adults die in our great cities through
heat stroke. As will be seen later there seem to be strong
reasons for believing the infant more sensitive to heat than
the adult, so there can be no ground for thinking that when
adults perish, infants escape. It has been stated, in the fore-
going, that hot days are accompanied by a number of deaths of
infants with acute symptoms not referable to the gastro-
intestinal tract. It is probable that a goodly proportion of
these are cases of heat stroke.
While references to heat stroke, in infants, in the literature
are, by no means numerous, a number of cases have been re-
ported by Illoway ( 21 ), Zahorsky ( 68 ), Snow ( 60 ), Finkel-
stein ( 9 ), Neuman and Japha (according to Kietschel), Kiet-
schel ( 56 ), Liefmann and Lindemann ( 87 ), Meyer ( 46 ), and
others. They were often breast-fed infants, were usually in
J. W. SCHERESCHEWSKY, M. D. 110
good health, but, for the most part, of the fat pasty type. In
most instances some prodromal symptoms of restlessness and
fretting have been present, after which the baby was taken
suddenly ill, often in the evening, with loss of consciousness,
high fever, hot skin and convulsions. The urine, when exam-
ined was found to contain casts and acetone (in one case
sugar, Finkelstein). With prompt hydrotherapy cures have
been effected in many instances, while, in others, rapid death
has ensued.
But, after all, only a small percentage of infants die dur
ing the summer in this fashion. Illoway estimates their num
ber at two to three per cent of the total infant deaths ; Finkel-
stein at six or seven per cent. These are simple guesses, for
which there is no statistical verification.
Besides thermic fever, we have two other types of affec-
tions especially fatal to infants in hot weather (a) typical
cholera inf antum, running a rapidly fatal course with watery
diarrhea, vomiting, high fever and, frequently, convulsions,
and (b) the sub-acute diarrheas which may last for days or
weeks before a fatal termination.
It will be well, at this point, to run over the principal ef-
fects which have been noted as to the action of heat upon
the organism.
Tolerance of heat. With respect to adults, Rubner ( 58 )
found that temperatures in excess of 24 centigrade and rela-
tive humidities of 80 per cent caused symptoms of heat reten-
tion to make their appearance in adults. The experiments of
Fliigge, Paul, Ercklentz and Heymann have already been
referred to as to the effects of stagnant air in setting up
symptoms of heat retention.
Haldane ( 15 ) found that moderate work at wet-bulb temper-
atures in excess of 25.5 C. (78 F.) impracticable by reason
of symptoms of heat retention.
Effects of Heat upon Metabolism. With rising tempera-
tures the heat eliminated from the body by means of radiation
and convection becomes progressively less until a point is
reached in which all the labor of heat elimination is per-
formed by the evaporation of moisture. Eanke ( 53 ) points out
that when the body has to choose between the quantity of
food necessary for nutrition and that consistent with heat
regulation, it is compelled to choose the latter in self-defense.
As a consequence, in hot weather, the appetite is greatly re-
duced.
As a result of calorimetric measurements, Eanke found that,
with mean temperatures of 25 0. the intake of food sank,
120 HEAT AND INFANT MORTALITY
in adults, to energy values, below those represented by the
metabolism of the fasting, resting adult.
Another effect of heat is to depress the anabolic processes.
Thus L. F. Meyer ( 46 ) found while the weekly gains in weight
by the infants at the Berlin City Orphanage during the rela-
tively cool months of July and August, 1910, were 590 and
600 grams, respectively, in the very hot months of July and
August, 1911, these were but 290 and 350 grams.
Heat, sufficient to cause rises in the rectal temperature of
the resting adult and other symptoms of heat retention has
also the property of accelerating the rate of metabolism. Sut-
ton ( 61 ) found that in an adult exposed to relatively high
temperatures (37 0.) that, in addition to the symptoms of
heat retention, the respiratory exchange and the respiratory
quotient were raised. He concludes that high temperatures
accelerate the metabolism as heat does any simple chemical
reaction. In this way a vicious circle is established.
Evaporation of Moisture. While it is a matter of common
knowledge that heat greatly increases the amount of water
evaporated by the body there is interest in referring to the
amount of this loss. Hunt ( 20 ) found that with high dry
temperatures (wet-bulb around 70 F.) and exercise as much
as 13^ litres of water were taken daily and yet the secretion
of urine was then by no means free. In another series of
observations he found that, in spite of frequent drinking, 16
hours were required to replace water evaporated from the body
during a day's experiments in the hot room. In these latter
experiments the hemoglobin index of the blood was the same
before and after exposure to the heat. Therefore, the source
of the water evaporated was the tissues of the body.
Effect of Heat upon the Digestive Secretions. There is
evidence to show that the activity of the digestive glands
especially the stomach, are depressed by heat. v. Salle ( 59 )
found that exposures to moderately high temperatures (29
to 31 C. (84.2 to 87.8 F.) had the effect of greatly dimin-
ishing not only the amount of the gastric secretions, but
their acidity and digestive activity. In this way the stomach
not only loses a portion of its power to act upon food, but,
from the diminished or absent acidity, there is a corresponding
loss in the antiseptic and antifermentative action of the gastric
juice.
Effect of Heat upon the Resistance to Bacteria. The ob-
servations of Medowikow ( 40 ) show that exposure to heat has
the effect of diminishing the resistance of young animals to
bacteria, in the intestinal tract. Medowikow exposed young
J. W. SCHERBSCHBWSKYj M. D. 121
rabbits to incubator temperature for 12 hours. He found, at
the close of the experiment, that, not only were the bacteria
in the intestinal tract increased, but also, in nine cases out of
ten, B. coli was present in the spleen or the liver.
Effects upon the Infant Organism. Let us now examine in
what way the results enumerated above can be interpreted
with respect to infants.
Metabolism of the Infant. In the first place the metabolism
of the infant is keyed to a much higher plane than that of
the adult. According to Nieman ( 47 ) the respiratory exchange
of the infant is higher than that of the resting adult and
corresponds to that of an adult doing moderate work. The
total metabolism of infants is about 100 calories per kilogram
and from 50 to 90 calories are required, exclusive of the
amounts retained for the purpose of growth. This corresponds
to the metabolism of an adult doing fairly severe muscular
work.
Another evidence of the more active metabolism of the in-
fant is shown by the skin temperature. Eubner ( 58 ) found
that a thermometer placed between the skin of an adult's
chest and a woolen undershirt registered about 32 C. Lief-
mann and Lindemann ( 3T ) state that thermometers inserted
between the skin and clothing of infants registered between
34 and 35 C.
Since the metabolism of infants is higher they produce
much more heat than the adult in proportion to their weight.
Though it is true that they have also a proportionately
greater skin surface to provide for the elimination of this
increased amount of heat, it must follow that when the escape
of heat is prevented by meteorological conditions, their
greater rate of metabolism must favor heat retention.
TTiermo-Regulation in the Infant. We can deduce from the
above, for the infant, narrower temperature limits within
which heat regulation is efficient than for adults and, conse-
quently, a more labile condition of temperature equilibrium.
Experimentally, such has proved to be the case. The observa-
tions of Genersich ( u ), Eietschel ( 57 ), Kleinschmidt ( 27 ) ;
Heim and John ( 1T ) show that when infants are experiment-
ally exposed to moderately high heat (28 to 32 0.) a rise
in their body temperatures takes place. This rise was found
to be greater in infants suffering from disturbances of the
nutrition (Kleinschmidt, Eietschel).
Meinert ( 42 ), in his investigations in Dresden, found that
the rectal temperatures of infants, in homes where the in-
122 HEAT AND INFANT MORTALITY
door temperatures were high, were increased to 39 or 40 0.
at night, although, according to the parents' statements, the
infants had been comparatively well.
Reduction of Tolerance for Food. Another effect of heat
is the reduction of the tolerance for food. Kanke's observa-
tions in respect to this effect of heat upon adults have al-
ready been mentioned. The adult, however, taking both solids
and liquids, can diminish the one and increase the other.
Meinert ( 41 ) points out that, in the breast-fed infant this
demand for increased liquids is regulated by the breast, for,
as a result of numerous observations, he has found that breast-
milk is more fluid in the summer than in the winter. Indeed,
this is to be expected, as, in hot weather, the mother will
instinctively drink more and eat less.
Besides this v. Pirquet ( 51 ) also points out that, not only
the quantity, but the quality of the food obtained by the
breast-fed child is influenced by its appetite. In hot weather,
when this is reduced, it quickly ceases to suck, hence it re-
ceives only the more fluid "fore-milk," while the rich "after-
milk" remains in the breast.
The bottle-fed child is far more passive than the breast-
fed with respect to its food, which it obtains with a minimum
effort through the effects of gravity. It, therefore, varies its
intake far less than the breast-fed child. Moreover, its in-
creased thirst often leads mothers to satisfy it with additional
food instead of water.
It is obvious, under these conditions that bottle-fed babies
are often relatively over-fed, in hot weather, a circumstance
commented on by numerous authors.
Another effect of heat of importance to the digestion of
infants is the diminution of the quantity, acidity and activity
of the gastric juice, as shown by v. Salle's experiments and the
resistance of the intestinal tract to bacteria as demonstrated
by Medowikow.
Not only will the digestive processes take place with greater
slowness, thus favoring stagnation of the intestinal contents,
but the deficient acidity of the gastric juice may, doubtless,
permit pathogenic germs which would otherwise succumb to
its acidity, to gain access to the intestine. The diminished
resistance of the intestinal epithelium would permit the pro-
liferation of germs introduced in this manner or favor endog-
enous infections.
We see from the foregoing that there are a number of rea-
sons why heat should exercise a particularly deleterious in-
J. W. SCHERESCHEWSKY, M. D. 123
fluence on infants. There remains for final examination the
possible effects of heat in respect to cholera infantum and
the sub-acute intestinal infections.
EFFECT OF HEAT IN PRODUCING CHOLERA INFANTUM
Typical cholera infantum has always been regarded by the
earlier American authors (cf. Miller) as a heat effect. The
following reasons have been advanced by Meinert, Eietschel
and others for regarding it from this standpoint :
1. This severe form makes its appearance only after ex-
posure to very hot weather or high in-door temperatures.
2. It often attacks infants hitherto in the best of health.
Meinert found that 54 per cent of all the infants whose deaths
he investigated had always enjoyed good health, while Johns-
ton ( 24 ) from his observations in Leicester places this number
at 75 per cent.
3. The bacteriological findings and post-mortem appear-
ances in cholera infantum are far more indefinite than in the
sub-acute intestinal affections.
4. High fever is usually present.
5. A heat effect may be inferred e$ juvantilus or, in other
words, the most effective treatment is removal to a cool loca-
tion, hydrotherapy and restoration of the body fluids.
In this connection a case recited by Rietschel ( 56 ) is in-
structive. During the summer of 1911 an artificially fed in-
fant, receiving excellent milk, both from a quantitative and
qualitative standpoint, from the Dresden Saiiglingsheim, lived
in a dwelling where continuously high temperatures were
registerd. The infant bore the heat very well up to the 8th
of August. No diarrhea was present up to that time, the
bowels being somewhat constipated. On that date, slight
diarrhea made its appearance, but the child, while listless,
seemed comfortable. On the 9th the symptoms suddenly
changed. The diarrhea became spurting, and the child's temp-
erature rose to 40 0. The infant was quickly removed to the
hospital, where the fever was reduced by hydrotherapy. We
are not informed by Rietschel as to the subsequent fate of
the child.
Sub-Acute Diarrhea. While in this class of affections the
influence of heat is by no means so apparent, from the state-
ments already made, however, it must be conceded that heat
has important predisposing effects, in the following ways :
124 HEAT AND INFANT MORTALITY
1. By reduction of the tolerance for food.
2. By reduction of the activity of the digestive secretions.
3. By reduction of the normal resistance of the intestines to
bacterial invasions.
Clinical experience has shown that stormy symptoms can
be induced by feeding infants excessive amounts of the purest
food, from the bacteriological standpoint. The relative reduc-
tion of the tolerance for food, by the action of heat must, as
has already been pointed out, produce many instances of over-
feeding, leading to nutritional disturbances.
The continued influence of heat upon the infant, whose
nutrition has been thus disturbed, leads to impairment of the
thermal regulation, which is more labile in children with
digestive disturbances. This, in turn, has the effect of still
further lowering the tolerance for food, so that, in this way,
a vicious circle is established. Added to this, are the weak-
ness of the digestive secretions, the stgnation of food in the
intestine and the increased susceptibility to exogenous and
endogenous infections.
It seems clear, from the foregoing, that we must regard
heat as a powerful factor in directly determining the sum-
mer mortality of infants. Yet to ascribe all of summer mortal-
ity exclusively to this cause would be as one-sided as to ascribe
it all to the method of feeding.
I think, however, that the recent observations recorded
have furnished us with lines of much greater precision on
which to base our preventive measures. Our attention has,
besides, been especially directed anew to the influence of
poor housing conditions in the production of summer deaths
in babies.
The indications for prophylaxis are plain. They consist,
hand in hand, with an improvement in housing conditions and
the development of residential suburbs, in a greater emphasis
upon the care of infants in their homes in the summer months.
Mothers must also be informed of the fact that excessive heat,
per se, is deleterious to infants and, when hot weather is
present, special efforts must be made to prevent overheat-
ing and relative overfeeding of babies by the use of fre-
quent tepid baths, light clothing, fresh air, increase in the
amount of water given, lengthening of the feeding intervals
and reduction in the amounts of food. The advantages of
breast-feeding are only emphasized by all that has been
brought out. Here nature automatically modifies the composi-
tion of the food in accordance with the heat in a way to which
artificial feeding can never compare.
J. W. SCHERESCHEWSKY, M. D. 125
CONCLUSIONS
1. The action of heat as a direct cause In the summer mor-
tality of infants has been greatly underestimated in the last
twenty-five years. In the future much more weight should be
given to its influence.
2. The lethal action of heat is a function, not so much of
the maximum and mean temperatures of the external air as
of the in-door temperatures, which, in the late summer may
continue to be high, in spite of remissions in temperature of
the external air.
3. The action of dirty and stale milk in causing the death
of infants, has been given a significance which has overshad-
owed other factors of equal or greater importance.
4. There is evidence to show that a certain proportion of
infant deaths are due to specific infections, in the dissemina-
tion of which contact infection and flies doubtless play a
part.
5. As a result, future activities for the prevention of in-
fant mortality must concentrate themselves to a greater extent
on the question of housing, especially the factors productive
of high in-door temperatures, such as overcrowding, narrow
streets and the absence of through ventilation.
6. Poor housing conditions can be partially neutralized by
the proper care of babies in the summer. The general public
should be educated as to the importance of high in-door temp-
eratures in causing the death of infants, and, especially, as
to measures which prevent babies from suffering from the
heat.
7. Breast-feeding must still be regarded as a most, if not
the most important preventive of the summer death of infants.
126 HEAT AND INFANT MORTALITY
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aiiseren Agentien. Arch. f. Kinderh., 1910-11, Vol. 55, pp. 214-256.
41. Meinert E. Untersuchungen fiber den Einfluss der Lufttemperatur auf
die Kindersterblichkeit an Durcbfallskrankhetten. Deut. Med.
Woch., 1888, Vol. 14, pp. 491-493.
42. Ueber Cholera Infantum aestiva. Therapeut. Monatsh., 1891, Vol. 5, pp.
520 ; 567 ; 623.
43. Miller, Clark. A contribution to the etiology, pathology and therapeutics
of cholera infantum. Am. Journ. Obstet., 1S79, Vol. 12, pp. 236-
251.
44 Morgan, H. deR. Upon the bacteriology of the summer diarrhoea of in-
fants. Brit. Med. Journ., 1906, pp. 908-912.
45 Morgan & Ledginham. The bacteriology of summer diarrhcea. Proc. Roy,
Soc. of Med., II, Part 2 ; pp. 133-149.
46 Meyer, L. F. Die Morbiditat und die Mortalitat der Saiiglinge in Som-
w. meyer, i^ ^^ Verhandl. d. Gesellsch. f. Kinderh., Deut. Naturf,
Aert, 1911, Vol. 28, 1912, pp. 55-61.
47. Niemann. Der Gesamtstoffwechsel eines Kunstlich gen|hrten Saiiglings.
Jahrb. f. Kinderh. u. physiche Erzh., 1911, Vol. 74, p. 62.
48. Niven, J. Manchester Health Officer's Reports (1904-8).
49. Park, Wm. H., & Holt, L. Emmett. Report upon the results with different
kinds of pure and impure milk in infant feeding in tenement
houses and institutions in New York City. Studies Rockefeller
Inst. Med. Research, 1904, Vol. 2, pp. 1.29.
50 Peters O H. Observations on the natural history of epidemic diarrhoea.
' Journ. Hyg., 1910, Vol. 10, pp. 602-777.
51 v. Pirquet, C. Schematische Darstellung der SaugUngsernahrung zur
q Unterrichtszwecken. Zeit. f. Kinderh., 1910-11, Vol. 1, pp. 118
et seq.
128 HEAT AND INFANT MORTALITY
52. Pransnitz. Sommersterblichkeit der Saiiglinge Verhandlung der Gesell-
schaft fur Kinderheilk. Gsl. Deut. Naturf. u. Aertzte, 1911
Wiesbaden, 1912, Vol. 28, pp. 1-25.
53. Ranke, K. E. Ueber die Abhangigkeit der Ernahrung vom Warmehaushalt
nach Versuchen in den Tropen, im gemassigten Klima und im
Eochgebirge. Munch. Med. Woch., 1905, No. 2, pp. 64-68.
54. Rietsehel, H. Die Sommersterblichkeit der Satiglinge. Brgebnisse d. inner
Med. u. Kinderh., 1910, Vol. 6, pp. 369-490.
55. Sommerhitze Wohnungs temperature und Sauglingssterblichkeit. Zeit f
Kinderh., 1910-11, Vol. 1, pp. 546-571.
56. Die Sommersterblichkeit der Saiiglinge. Verhandl. d.
Versamml. d. Gesell, f. Kinderh. Deut. Naturf. u. Aertze, 1911
Wiesbaden, 1912, Vol. 28, pp. 26-54.
57. Zur Aetiologie des Sommerbrechdurchfalls der Sauglinge
Monatschr. f. Kinderh., 1910-11, Vol. 9, pp. 39-51.
58. Rubner. Lehrbuch der Hygiene, 1907, 8th ed.
59. v. Salle. Ueber den Einfluss hoher Sommertemperatur auf die Funktion
des Magens. Verhandl. d. Versamll. d. Gesellsch. f. Kinderh.
Deut. Naturf. u. Aertze, 1911, Wiesbaden, 1912, Vol. 28, pp. 72-83.
60. Snow, Irving M. Heat stroke in infants. Arch, of Fed., 1898, Vol. 15
p. 741.
61. The influence of high temperatures upon the body, especially with regard
to heat stroke. Journ. Path, and Bact, 1908-9, Vol. 3, pp. 62-73.
62. Waite, W. W. Studies of the diarrhceal diseases of infancy. Studies
Rockefeller Inst. Med. Research, 1904, Vol. 2, pp. 71-75.
63. Willim, R. Ueber die Beziehungen zwischen Sauglingssterblichkeit und
Sommertemperatur. Zeit. f, Hyg. u. 1908-9, Vol. 62, pp. 95-130.
66. Wollstein, M. The dysentery bacillus in relation to the normal intestines
of children. Studies Rockefeller Inst. Med. Research. 1904, Vol.
2, pp. 193-202.
67. Wollstein, M., & Dewey, G, Studies of diarrhoeal diseases of infants.
Studies Rockefeller Inst. Med. Research, 1904, Vol. 2, pp. 55-66.
68. Zahorsky, J. Thermic fever in infants. Pediatrics, 1898, Vol. 5, p. 143.
DISCUSSION
Dr, T. B. Cooley, Detroit : We know that there is a very obvious
relation between summer heat and infant mortality, but in
spite of all the work that has been done lately upon this sub-
ject, the precise nature of the effect of heat is still not clear.
Apparently a great proportion of the increased mortality dur-
ing the hot season is due to a lowering of the child's resistance
to such factors as over-feeding, ill-judged feeding, spoiled food,
and specific infections. We have still to learn just how this
indirect effect of the summer heat is produced, but it has been
clearly shown that a great part of it can be avoided by im-
proving housing conditions. It is a striking fact that improve-
ment in housing conditions seems to have considerably more
effect in lowering the summer mortality than improvement of
the milk supply. Heat and moisture inside the house, and
summer hygiene aside from the feeding question are apparent-
ly the first things to attack. It is possible to do harm by over
emphasizing bad milk. The majority of general practitioners
still believe that summer diarrhea is due to bad milk. So
DISCUSSION 129
long as the profession continues to lay all summer diarrhea
to this cause, not enough attention will be given to other rea-
sons for the high summer mortality. We hesitate to admit
that impure milk is not responsible for so much trouble as we
once thought, because we are afraid people may be encouraged
to use it. It seems to me that the profession and laity should
understand that clean milk alone will not solve the problem.
Inasmuch as we all realize that we do not know so much
as we should like about summer mortality, and that there is
a great field for further work in that line, I wish to offer the
following resolution:
RESOLVED, That, considering the great importance of further accurate
scientific study of the relation between summer heat and infant mortal-
ity, the American Association for Study and Prevention of Infant Mor-
tality respectfully suggest to the United States Public Health and Ma-
rine Hospital Service the desirability that such a study be undertaken
under the auspices of this Service.
Dr. Fritz B. Talbot, Boston: I want to put myself on record as
disagreeing with Dr. Cooley in saying that there are things of
more importance in causing summer diarrhea than dirty milk,
I believe in Boston dirty milk is responsible for the majority
of deaths from summer diarrhea and infectious diarrhea.
Heat may be a predisposing factor toward impure milk; but
heat is not a more important factor in causing death of infanta
in summer than dirty milk.
Dr. I. A. Abt, Chicago : Several years ago I presented a paper
on this subject at a meeting of the Section on Diseases of Chil-
dren of the American Medical Association, which met at Los
Angeles, and a great many doctors wondered what I was talk-
ing about. Those from New Mexico and Arizona and South-
ern California said that they had no such experience; they
had no summer mortality. So there must be something he-
sides the heat. There must be such an element as humidity
that is not thoroughly understood. I think that some of
these conditions are due to the debility caused by the heat.
Every one is prostrated and not able to do his best, and that is
true throughout the temperate zone. I presume that the
baby feels it, especially if he is living in an unsanitary home,
or has been badly treated all winter. Babies bear extremes of
temperatures badly. Nobody has studied the effect that cold
would produce. I do not believe a baby could stand excessive
cold any more than excessive heat. Every one knows that
Arctic explorers are rendered feeble, and many die on account
130 HEAT AND INFANT MORTALITY
of the effects of long-continued cold, and those who travel in
the tropics tell us that the debility is very great. Dr. Epstein
has had a large number of deaths in his infant asylum. It
seems to me we make very little progress when we tell people
dirty milk is bad and clean milk is good. Then without good
and sufficient reasons, are we willing to say it is not the milk
at all ? I think the best and the purest milk is none too good
for the babies. I am in favor of pure certified milk.
Dr. H. L. K. Shaw, Albany: I agree with the last speaker
that there is something more than heat responsible for
this trouble. Humidity combined with heat has its effect on
infant mortality. With relatively high temperature and high
humidity we get a lower resistance and a tendency toward
diarrheal affections. We should carefully supervise the feed-
ing when the temperature and humidity are high. By that
means I believe we will be able to reduce the morbidity of
children in the ward. The same thing can be done in private
practice. One can also remove the child from the upper floors
and put him downstairs where the temperature is lower or ? if
a hospital patient, one can remove him from the corner with
the screen around him and put him where he will have a circu-
lation of air.
Dr. Herman Schwarz, New York: I want to impress upon
the Association the amount of work that a paper of this kind
entails. In 1910 I went through the records of the City of
New York, getting the daily deaths and the daily tempera-
tures. At the time I got those statistics there wasn't such a
thing as a death rate of infants obtainable. Deaths were
classified as being under five years. I took the temperature
of apparently normal infants. Breast-fed babies in the tene-
ments often had a temperature of 101 in the summer. What
was the cause of this high temperature and high mortality,
we do not know. I think Dr. Cooley is rather indiscreet in
putting it this way before this society. We are not all physi-
cians, and even for physicians I think it would be indiscreet
to let that statement go out. I think Dr. Abt put it very well.
We have got so far and let's leave that alone. We want not
only good milk, but we want everything else that's good. Dr.
Cooley certainly means that we should have pure milk, but in
addition to that I will agree with him that pure milk is not
the only thing. We need also proper housing and adequate
ventilation. Pure milk and a great deal of fresh air are essen-
tial. As long as our cities are built as they are, block upon
block, we will have summer infant mortality. We are making
an interesting study at the Mount Sinai Hospital. We have a
room there the temperature of which can be reduced about
ten degrees. We have not had enough cases yet to discuss
it. If you have a high temperature in the beginning of the
summer, say in June, you will find that infant mortality
will be greater in July and August than it would be if June
were not so hot. Those children get something in the begin-
ning that reduces their vitality, and later on they cannot
resist the heat and they die under even less heat as the result
of the continued intestinal disturbances.
Dr. Wm. C. Woodward, Washington, 33. C.: It is late in the
day to begin to debate the relation of milk to infant mortal-
ity. The data pertaining to that subject are too numerous and
too definite to permit of two opinions to any one who is
familiar with it. That does not mean that there may not be
other causes that contribute to infant mortality. It does not
mean that weather conditions and housing are not contributing
causes. I would like to offer, therefore, to any member of the
Association who is interested in statistical studies, statements
published in each of the annual reports of the Health De-
partment of the District of Columbia from 1882 to 1902
twenty years showing the number of deaths that occurred
among children in the first two days of life, on each day of
that period, and on each day of that entire twenty years among
children during the first five days of life. You will find in
the same table for each of the same days a statement of the
mean barometer reading; mean relative humidity; the maxi-
mum, minimum and mean readings of the thermometer (ex-
posed bulb), and its range; the mean reading of the wet bnlb
thermometer ; the mean dew point ; the direction of the wind at
8 o'clock A. M., and at 8 o'clock P. M,, and its total movement
in miles; and the total rainfall. If any one will undertake
the analysis of these data, I will be glad to help him in any
way I can.
Dr. T. B. Cooley, Detroit : I believe good milk is better than
poor milk. But all the same, bad milk is not sufficient to point
to as the reason for all infant diarrhea. We must find other
causes.
Dr. Julius Levy, Newark, N. J.: When we started a rather
extensive infant consultation service in Newark, many of
the infants that came to us the first summer had diarrhea
and continued to have it in spite of what we gave them. The
next summer very few came with diarrhea, and the past two
130 HEAT AND INFANT MORTALITY
of the effects of long-continued cold, and those who travel in
the tropics tell us that the debility is very great. Dr. Epstein
has had a large number of deaths in his infant asylum. It
seems to me we make very little progress when we tell people
dirty milk is bad and clean milk is good. Then without good
and sufficient reasons, are we willing to say it is not the milk
at all ? I think the best and the purest milk is none too good
for the babies. I am in favor of pure certified milk.
Dr, H. L, K. Shaw, Albany: I agree with the last speaker
that there is something more than heat responsible for
this trouble. Humidity combined with heat has its effect on
infant mortality. With relatively high temperature and high
humidity we get a lower resistance and a tendency toward
diarrheal affections. We should carefully supervise the feed-
ing when the temperature and humidity are high. By that
means I believe we will be able to reduce the morbidity of
children in the ward. The same thing can be done in private
practice. One can also remove the child from the upper floors
and put him downstairs where the temperature is lower or, if
a hospital patient, one can remove him from the corner with
the screen around him and put him where he will have a circu-
lation of air.
Dr. Herman Schwarz, New York: I want to impress upon
the Association the amount of work that a paper of this kind
entails. In 1910 I went through the records of the City of
New York, getting the daily deaths and the daily tempera-
tures. At the time I got those statistics there wasn't such a
thing as a death rate of infants obtainable. Deaths were
classified as being under five years. I took the temperature
of apparently normal infants. Breast-fed babies in the tene-
ments often had a temperature of 101 in the summer. What
was the cause of this high temperature and high mortality,
we do not know. I think Dr. Cooley is rather indiscreet in
putting it this way before this society. We are not all physi-
cians, and even for physicians I think it would be indiscreet
to let that statement go out. I think Dr. Abt put it very well.
We have got so far and let's leave that alone. We want not
only good milk, but we want everything else that's good. Dr.
Cooley certainly means that we should have pure milk, but in
addition to that I will agree with him that pure milk is not
the only thing. We need also proper housing and adequate
ventilation. Pure milk and a great deal of fresh air are essen-
tial. As long as our cities are built as they are, block upon
block, we will have summer infant mortality. We are making
DISCUSSION 131
an interesting study at the Mount Sinai Hospital. We have a
room there the temperature of which can be reduced about
ten degrees. We hare not had enough cases yet to discuss
it. If you have a high temperature in the beginning of the
summer, say in June, you will find that infant mortality
will be greater in July and August than it would be if June
were not so hot. Those children get something in the begin-
ning that reduces their vitality, and later on they cannot
resist the heat and they die under even less heat as the result
of the continued intestinal disturbances.
Dr. Win. C. Woodward, Washington, ]). C.: It is late in the
day to begin to debate the relation of milk to infant mortal-
ity. The data pertaining to that subject are too numerous and
too definite to permit of two opinions to any one who is
familiar with it. That does not mean that there may not be
other causes that contribute to infant mortality. It does not
mean that weather conditions and housing are not contributing
causes. I would like to offer, therefore, to any member of the
Association who is interested in statistical studies, statements
published in each of the annual reports of the Health De-
partment of the District of Columbia from 1882 to 1902
twenty years showing the number of deaths that occurred
among children in the first two days of life, on each day of
that period, and on each day of that entire twenty years among
children during the first five days of life. You will find in
the same table for each of the same days a statement of the
mean barometer reading; mean relative humidity; the man-
mum, minimum and mean readings of the thermometer (ex-
posed bulb), and its range; the mean reading of the wet bulb
thermometer ; the mean dew point ; the direction of the wind at
8 o'clock A. M., and at 8 o'clock P. M., and its total movement
in miles; and the total rainfall. If any one will undertake
the analysis of these data, I will be glad to help him in any
way I can.
Dr. T. B. Cooley, Detroit : I believe good milk is better than
poor milk. But all the same, bad milk is not sufficient to point
to as the reason for all infant diarrhea. We must find other
causes.
Dr. Julius Levy, Newark, N". J.r When we started a rather
extensive infant consultation service in Newark, many of
the infants that came to us the first summer had diarrhea
and continued to have it in spite of what we gave them. The
next summer very few came with diarrhea, and the past two
132 HEAT AND INFANT MORTALITY
summers we hardly had a case of diarrhea. I believe the
diarrhea at first was due to the fact that the cases had been
fed improperly and with poor judgment. The main thing is to
feed the infant correctly from birth. We have emphasized in
our work that at the first approach of warm weather, feeding
must be cut down. I don't believe it's best to wait for the
indication of the bulb thermometer. Our experience in elim-
inating a larger proportion of diarrhea bears out Dr. Scheres-
chewsky's conclusions. Bad results come when we do not
adapt ourselves to the heat If we so take care of our infants
and so educate our mothers to adapt themselves to the in-
creased heat, the heat will not have such a bad effect.
The Chairman: If there is no further discussion I will ask
Dr. Schereschewsky to close.
Dr. Schereschewsky: I hope we have not been advocating
anything that is retrogressive as regards the safeguarding of
the milk supply. We must control our milk more rigidly than
ever, and yet mothers and physicians need not think that the
child is absolutely guaranteed from summer diarrhea as long
as it is receiving only pure milk. There are other things that
we must pay attention to, and especially must we pay atten-
tion to the heat in the home. If we can lay emphasis on the
need for improved housing conditions and on the need for
cool indoor temperatures we will be on the road to make great
progress in solving the problems of infant mortality.
SESSION ON EUGENICS
EUGENICS
Saturday, November 15, 10.30 A. M,
CHAIRMAN
PROF. H. E. JORDAN, University of Virginia, Charlottesville
SECRETARY
PROF. ROSWELL JOHNSON, University of
STATEMENT BY THE CHAIRMAN:
We are interested here today in the conservation of the
most precious thing in the world human life. The funda-
mental asset of a country is its child product. The world
moves forward, as has been said, upon the feet of little chil-
dren. Real national progress depends upon the quality, rather
than the quantity, of the child product. An organism may be
said to be the product of the interaction of its inheritance and
its environment. In organic development both heredity and
environment are absolute essentials ; moreover, the action of the
one complements that of the other. If the environment is bane-
ful or deficient in any one of many possible ways, one expres-
sion of the effect will be in increased infant mortality. Simi-
larly, if the inheritance be of low quality or defective the prev-
alence of infant mortality will be extended.
The Eugenic Section stresses primarily this factor of hered-
ity as it affects infant mortality. The factor of environment
acting either upon the unborn or newly-born infant, will be
cared for by other sections of this association. Effective efforts
for infant conservation must include attention to both, hered-
ity and environment. It is one of the chief functions of our
section to emphasize the importance of heredity.
The aim of this association is to save and bring to maturity
all infants born. Paradoxical as the statement may at first
seem, it is obvious that the more fully we succeed in realizing
our ideal, the more need for our efforts in the future and the
133
134 EUGENICS
greater in time will become the infant mortality rate. For
weakness breeds weakness as like produces like. A weakened
constitution, with a lack of "biological capital," more easily
succumbs to death. About ten per cent of our population is
estimated to be defective, i. e., grossly, obviously, seriously
and universally admitted, defective, and so a racial menace.
If we succeed in raising all infants, obviously some unfit stock
will be preserved to reproduce its defective type, and work
injury to the race. Theoretically from a cold scientific stand-
point, a certain small amount of differential infant mortality
must obviously be a good thing. But even if morally and
socially allowable which it is not no discriminating pro-
cedure would be practical. For it is impossible by present
means to distinguish absolutely and certainly in early infancy
between the potentially fit and strong and the grossly unfit
and weak. I want to state with all the emphasis I can com-
mand that we cannot lower our ideal. The same serious effort
must be made to rear all infants. But we must at the same
time recognize the fact that some unfit stock, reproducing in
geometrical ratio, is thus saved to reproduce its defective type
and to contaminate the race. This simply means that our
efforts for infant conservation must be extended to embrace
an interest also in potential parents and to seek means to
prevent reproduction on the part of those racially seriously
deficient. Our efforts may defeat our aims unless the mass
of the babies we save are racially of sound stock.
Two prime morbid conditions with possibly important hered-
itary aspects contributing largely to the quota of infant mor-
tality are syphilis and tuberculosis. We shall have these two
subjects presented to us this morning by able scientific men,
specialists, and I trust that they will be followed by full and
free sympathetic discussion.
The Chairman: The first paper on our program is by Dr.
Charles B. Davenport, of Cold Spring Harbor, Long Island,
N. Y., on "Besults from Experimental Breeding Bearing Upon
the Problem of Infant Conservation." In order that we may
have some discussion I will ask the secretary to read the ab-
stract as it is printed in our program, since Dr. Davenport is
not present.
The secretary read Dr. Davenport's abstract, as follows :
"The quickest way to produce desirable combinations in
plant and animal breeding is by mating parents that belong
to two strains whose best qualities it is desired to unite and
MRS. JOHN HAYS HAMMOND 135
then by selecting a very few of the best individuals and de-
stroying all the rest. Indeed, the animal and the plant breeder
knows that he makes progress most rapidly the more extensive
his elimination.
"Care in the selection of marriage mates is capable of doing
much to increase the proportion of those who would be a
credit to the race if they should survive, but good marriage
selection alone is entirely inadequate to replace the beneficent
agent of extensive infant mortality, i. e., from the standpoint
of physical, social welfare; and as indicated by the results of
experimental breeding. Among the "'children of nature" we
understand that infant mortality is fairly high and maintains
a high physical if not mental status of the race. The elimina-
tion of the beneficent action of selection would probably cause
deterioration of the average of such savage races, and the
same effect within limits will follow among the more cultured
strains also.
The Chairman: I have the pleasure of calling upon Mrs.
John Hays Hammond for a brief discussion of this paper of
Dr. Davenport's.
THE EDUCATION OF PARENTS IN PRACTICAL EUGENICS A FACTOR
IN THE PREVENTION OF INFANT MORTALITY
Mrs. John Hays Hammond, Washington: Analysis of statis-
tical figures shows that the heaviest toll of infant mortality is
on the first day of life. The number of deaths from the first
day is three times as great as for any succeeding day, is
greater than the combined deaths of all other days of the first
week; and those of the first week equal those of the remaining
three weeks of the first month. The rate of mortality of the
first month is double that of any other month.
Here, it seems to me, is an important problem in the preven-
tion of infant mortality. How can the congenital biological
capital or birth endowment of the infant be increased so that
it will survive the first day, the first week, the first month, the
first three months, under hygienic conditions? A study of
death certificates gives very little information as to the cause
of these first day, first week and first month deaths. For ex-
ample, in 1910, an analysis of the causes of deaths of infants
in the District of Columbia, gave congenital debility, inanition
and marasmus for one-third of all cases, prematurity, malfor-
mations, infection of the cord, and convulsions for a like num-
ber, making a total of two-thirds of all infant mortality of the
District of Columbia in 1910 due for the most part to congen-
136 EDUCATION OF PARENTS IN PRACTICAL EUGENICS
ital conditions or to the inefficiency of the accoucher. From
these figures it seems that over one-half of the white coffin
procession in Washington is doomed to this fate before birth
or in the hour of birth.
So appalling are these figures that I believe it behooves
every mother to inquire, "Why did my baby die?" and every
girl to ask, "Why do not all women have rosy, plump, dimpled,
healthy babies?" The answer will be found in eugenics.
Eugenics teaches that much of infant mortality is due to the
fact that many babies are born with insufficient capital to
meet the demands of life.
Congenital debility or insufficiency of inherited biological
capital has been demonstrated to be due for the most part to
the health of the parents, to the action of certain poisons, as
syphilis, alcohol and tobacco, on the germ cells before their
union or after their fusion to form a new being; to the em-
ployment, the nutrition and sanitary housing conditions of
the mother during pregnancy.
These conditions are not only responsible for a large part
of infant mortality, but it has been demonstrated that they
are responsible for one-half of the fetal deaths, for one-half
of the morbidity of children, and for a large part of feeble-
mindedness and other forms of degeneracy.
It is not fitting that I, a lay woman, should recount here the
statistical familiar details to you all. But, bearing these facts
in mind, it seems to me that there is need of instruction in prac-
tical eugenics. I am so impressed with the need of such in-
struction that I believe there should be a great national move-
ment for the promotion of practical eugenics. By this I do not
mean an organization for scientific research. That work is
being done adequately by the Galton Laboratory, by Dr. Daven-
port and his co-workers at Cold Spring Harbor and elsewhere,
but I mean a national organization which will have for its
purpose such popularizing of the facts of the science of eugen-
ics that they can be incorporated into the real practical life
of the people, particularly the principles of negative eugenics
so admirably outlined by Dr. Jordan this morning. When
young women are made to realize that the defects as well as the
excellencies of their lovers will be reproduced in their chil-
dren, that men of intemperate and immoral habits are likely
to produce defective children, they will recoil from marriage
with such men. The old adage, "Marry a man to reform him,"
will lose its force.
Woman, rather than man, has always been the conserver of
race purity. In eugenics she will find an intelligent guide to
MRS. JOHN HAYS HAMMOND 137
the selection of a father for her children, to the elimination of
one-half of the morbidity of children., and to much of the use-
less waste of infant life. Young men and young women
should be instructed in the laws governing reproduction,
inheritance, infant welfare and child development. We need
more women to do work such as Dr. Elnora C. Folkmar is
doing in Washington, and Dr. Evangeline W. Young is doing
in Boston in instructing groups of mothers and teachers. We
need more twentieth century clinics such as Washington has
in the Woman's Clinic Auxiliary, where health and the educa-
tion of the actual and potential mothers is the chief end
sought. We need a well-equipped out-patient maternity service
in every community. We need more societies to discuss the
problems of infant mortality. We were all glad to hear Dr.
Holt tell last evening how many societies were studying
these problems. But we need most of all federal support in
this study. The eugenic hog has long been the subject of gov-
ernment research. The time is rapidly approaching when
women will demand that the eugenic child be recognized as a
worthy object of governmental expenditure. President Taft
is to be commended for his interest in furthering the establish-
ment of a Children's Bureau, and for the placing of a woman
at the head of it. Now we need a Federal Department of
Public Health. This, with its franking system, could carry the
message of eugenics to every home. In the meantime the work
of general education, the popularizing of the principles of
eugenics, should be undertaken by a great national organiza-
tion with headquarters at Washington. Such an organization
should publish a journal at least monthly, should organize
local round tables all over the country, should hold conven-
tions in every state, should syndicate eugenic articles in the
daily press. This is a big task. It is a very big task. But the
sooner some such well organized effort is made by all the
leaders in the movement, the sooner will infant mortality and
child morbidity be practically eliminated.
GENERAL, DISCUSSION
By a Member: I feel the cause of eugenics will not be
benefited by confusing things that come from environment
with things that come from heredity. We will understand the
problem better if we realize that environment extends nine
months before birth, and that the death of an infant on the
first day of life is the result of environment that is within
our control. The actual syphilis occurs during this environ-
138 DISCUSSION
mental period and is not a hereditary disease. If we will
call it an infection occurring before birth, we will understand
it better. It should not be classed among hereditary causes
even though it is transmitted to succeeding generations. Tuber-
culosis is also environmental, even though it may exist before
birth. Premature births, immature births that occur from
toxin, make a large group. There are three toxins : tubercu-
losis, fatigue and syphilis. Fatigue as a toxin will be found
most active in certain communities in the industrial cities of
Connecticut and Maine. Those who have been interested in
the briefs prepared by Louis Brandeis and Josephine Gold-
mark will realize the importance of that. It calls into play
some activity that influences environment at birth. Infants
die in the great mill towns of Maine and Massachusetts be-
cause the mothers work in factories until just before the baby
is born, and often return seven days after the baby is born.
So the same attack that would be made on the industrial
problem would control the conditions existing before birth.
Then it would direct our attention to the obstetric problem
which exists at birth. It is very important to make that thor-
oughly clear in this section. We will lose all the confidence of
scientific men if we confuse deaths that are the result of envir-
onment with those that are the result of heredity,
Tlie Chairman: The remark that I made in my introduc-
tion was that syphilis and tuberculosis are morbid conditions,
with possibly hereditary aspects. To get this before us we have
solicited for our program papers on syphilis and tuberculosis.
The point that must be kept clear is that eugenics rests upon
the fact of heredity, and the Eugenic Section must be based on
that principle.
Dr. Roy K. riannagan, Richmond, Va. : Dr. Davenport seems
to leave this matter not very clear. Apparently infant salvage
seems to be discouraged by him. I would hate to believe that
he means that, although it seems on the face of his paper that
way. He says : "The elimination of the beneficent action of
selection would probably cause deterioration of the average
of such savage races, and the same effect within limits will
follow among the more cultured strains also." I would ac-
cept it only as he says, as a mere statement of fact; but not
as a discouragement of the idea of universal infant salvage.
THE RELATION OF EXPERIMENTAL SYPHILIS TO EUGENICS*
HENRY J. XICHOLS, M. D., Captain, Medical Corps, U. S. Army
(From the Department of Pathology, Army Medical School,
Washington, B. C.)
Syphilis is generally conceded to be the worst of all the
infectious diseases in relation to the welfare of the next gen-
eration. Taken the world over, the only other specific disease
which can be compared to syphilis, in this respect, is gonor-
rhea ; and it is doubtful if the evil consequences of gonorrhea,
such as sterility in the prospective parents and blindness in the
children,, equal the sum total of damage which is traceable to
the spirochetes of syphilis, in the way of miscarriage and of the
flooding of the child's body with such dangerous and resistant
parasites. This is not the place to rehearse the tragedies of
conjugal and inherited syphilis; but the confidences of the
physician's office bring out the terrible reality of syphilis as a
family disease and the testimony of school teachers, of employ-
ers, of directors of homes for feeble-minded children and of
hospitals for the insane is eloquent in regard to the handicap
under which congenital syphilitics face life.
In the strict academic sense of a unit character bound up
in the chromosomes of the parents' germinal protoplasm,
syphilis is not hereditary for generations; although there are
authentic cases on record of the mechanical transfer of the
parasites of the disease to the third generation. However,
from the practical point of view of the welfare of the immedi-
ate offspring, syphilis is worse than a detrimental unit charac-
ter because the parasites are not limited to any one organ or
tissue but can and do permeate them all.
The dangers of the marriage of syphilitics have long been
known and the medical profession has long insisted on safe-
guarding the health of prospective parents and that of their
children by rules which covered the situation as far as exist-
ing knowledge permitted. Until recent years, however, our
knowledge of syphilis has been far from satisfactory and our
rules have frequently failed of their purpose. Within the last
decade our knowledge of the disease has been greatly enlarged,
especially by experimental and laboratory studies, and we are
139
140 RELATION OF EXPERIMENTAL SYPHILIS TO EUGENICS
now equipped with more efficient tests to determine the mar-
riageability of persons who have had syphilis and are better
prepared to prevent the advent of damaged successors.
Along with this increase of knowledge and partially depend-
ent on it has developed the modern movement of eugenics,
which is only a part of a larger movement for the control of
nature and society for human welfare and happiness. The first
essential of this movement is knowledge or science, for we
cannot act with good effect if we are in the dark. The second
essential is rightmindedness or the desire to use knowledge for
human welfare. When evils are brought to light, right minded
persons feel an irresistible impulse to correct them and the
eugenics movement along these lines is one of the most encour-
aging signs of the times. In the words of the most illustrious
living exponent of the larger movement we may say that the
eugenics movement is "a sure indication of the eternal forces
of human growth, of the God-given impulse implanted in man-
kind to make a better race and a better earth."
As has already been pointed out, the great recent advances
in our knowledge of syphilis have come from the laboratory
rather than from the clinic. Experimental syphilis is still a
young branch of syphilology and much work remains to be
done, but certain facts have been established and experimen-
tal syphilis has a claim for consideration because its findings,
once established, are more reliable than those of the clinic.
One of the best examples of the superiority of the experi-
mental and laboratory method over that of simple observation
of the patient is seen in the recent downfall of Oolles ? so-
called "Law." It has long been taught as an outcome of clin-
ical observation that an ''apparently" healthy mother of a
syphilitic child will not become infected by nursing or hand
ling her child, because in bearing a syphilitic child she has
become "immune" to the disease. It is usually true that the
mother under such circumstances does not become infected,
but as a result of experimental work and laboratory tests, we
now know that she does not become infected, not because
she is "immune," but because she herself has the disease,
usually in a so-called "latent" form. That is, she is only "ap-
parently" healthy and later on will pay toll to the hidden
parasites. The same is true of Profeta's so-called "law" which
relates to the "apparently" healthy child of a syphilitic mother.
The child is really not immune and really has the disease and
will suffer accordingly. There are many other aspects of the
disease which can be thoroughly understood and intelligently
HENRY J. NICHOLS, SI. D. 141
handled only by the production of the disease in animals and
by the study of it under the rigid conditions of scientific exper-
iment.
THE POSSIBLE AFFINITY OF SPIROCHAETA PALLIDA FOR THE
REPRODUCTIVE ORGANS
What is the explanation of the almost deadly certainty
that a syphilitic husband Trill infect his wife and that some,
at least, of their children will be born with the disease? As
a result of recent experimental studies in syphilis, we know
that the disease is a septicaemia in its early stages. The
virus is circulating* in the blood and has been recovered in
as high as 80 per cent of cases in this period ( 1 j. It would
not be surprising, therefore, that in this period the virus should
be transmitted in the marriage relation. But this is not the
stage in which the damage is usually done; more often it is
later in the disease, when the future father thinks he is cured,
that marriage occurs and the disease is passed on. Experimen-
tal syphilis has something to say on this subject and un-
doubtedly will have more to say in the future.
It cannot be stated as an established fact that Sp. pallida
has an especial affinity for the reproductive organs, but there
are several evidences of this insidious possibility. , The most
fruitful part of experimental syphilis has followed the trans-
mission of the disease to the rabbit and this field of work
remained limited until it was discovered that the sexual
organs are the best places for the multiplication of the para-
sites. It is a fact also that an intravenous injection of the
rabbit results first and sometimes only in lesions of the scro-
tum and testicle. Such observations are suggestive to say the
least. Along the same line of thought, Uhlenhuth has called
attention to the fact that the virus of dourine, a sexual dis-
ease of the horse, multiplies best in the testicle in experimen-
tal inoculations of the rabbit, either direct or intravenous.
Again, Neisser says that in infected monkeys the testicles are
more highly inoculable than milk or bone marrow. These
observations seem to indicate that infection of the reproduc-
tive organs is not merely a part of the general flooding of the
body with the parasites, but that the parasites actually have
an affinity for these tissues. If this is so, we may be dealing
with a character of the parasite which has been acquired in
order to perpetuate itself and if this is the case the disease
becomes just so much harder to combat. The solution of this
problem, which is a very practical one, can come only by the
experimental method.
142 RELATION OP EXPERIMENTAL SYPHILIS TO EUGENICS
Neisser ( 2 ) has reviewed this subject up to 1911. Spirochaetae
have never been found in the seminal fluid by direct micro-
scopical examination, but inoculation experiments have re-
vealed their presence. Neisser himself failed to infect mon-
keys in seven trials with fresh seminal fluid from cases in
various stages of the disease. Hoffman failed in three trials
with fluid from cases of 2y 2 months, 11 months and 18 months
standing. Finger and Landsteiner were successful in two
cases. In one the patient had had syphilitic orchitis so thai
this case can be ruled out. In the other case spermatic fluid
was obtained from a case in the secondary stage by expression
of the seminal vesicles and prostate; it was centrifuged and
injection of the centrifugate into a monkey resulted in a
definite syphilitic lesion. The fluid was apparently perfectly
normal and contained active spermatozoa. This result is a
distinct contribution to our knowledge of syphilis in relation
to eugenics. It also raises the question if the male sexual
element does not actually carry the virus.
Since 1911 the only work recorded in this line has been
done by Uhlenhuth and Mulzer( 3 ) who have confirmed Finger's
observation in so far as relates to the infectiousness of the
seminal fluid in the secondary stage. They obtained seminal
fluid from an early case with relapse after salvarsan and suc-
cessfully inoculated three rabbits. The entire fluid was used.
Seminal fluid from the same case after treatment' failed to
infect the rabbit.
It will be seen from these experiments that the seminal
fluid of secondary cases is infectious. We are still uncertain
about the seminal fluid of later cases, but clinical sugges-
tions are strong here and it remains for experimental syphilis
to say the final word. We are also in the dark about the
mechanism of infectiousness, whether the virus is in the fluids
or in the male elements themselves. The entire subject of the
relation of the spirochaetae to the female reproductive organs
is untouched. In the solution of these problems, little head-
way is to be expected, except by the experimental method.
Uhlenhuth and Mulzer have also taken up the difficult sub-
ject of experimental hereditary syphilis by breeding syphilitic
rabbits. The great practical difficulties of this subject are
apparent, but Uhlenhuth and Mulzer have already had some
success. They have shown that there is no immunity in young
born from syphilitic females and that the young may be in-
fected in utero by producing the disease in the mother. A
continuation of this work will probably yield very valuable
HENRY J. NICHOLS, M. D. 143
results. If known to our misguided friends who oppose the
experimental metliod ? this work will also probably provoke
the usual protest. This protest can be met by one question
which has never been satisfactorily answered by the "antis ?5
and until it is so answered, it must remain as a stumbling
block. The question is, how many rabbits is one human child
worth ?
THE EELATIONS OF SYPHILIS TO THE FAMILY
The relations of syphilis to marriage and the fruits of mar-
riage may be outlined as follows :
1. The husband has syphilis. He infects the wife and she
infects the embryo and has a miscarriage or an infected child.
This is probably the most usual occurrence, but as stated
above it is possible in some cases that the father infects the
ovum and that the mother is secondarily infected.
2. The husband has syphilis. He infects the ovum with-
out infection of the mother. This is very rare, if indeed it is
possible.
3. The wife lias syphilis and infects the child in utero;
the husband may be infected or not.
4. The wife is infected after conception and infects the
child.
In any case the result seems to be the same, the child is
infected and suffers accordingly. It may be said that in this
outline should also be included the more cheerful statement
that either the father or mother may have syphilis and the
child may be healthy. This may be true of the later children,
but in a given case any such statement, unless backed up by
the results of modern methods of examination, should be heard
with scepticism. If a child is born to syphilitic 'parents and
is not all broken out with sores on the skin, it is no sign that
the child is healthy. The evil consequence of syphilis may not
become evident for years afterward, and who has followed these
"apparently" healthy children for a sufficient length of time
to speak with certainty of the clinical results? The only
sure way is to use the laboratory tests available at present
and the more they are used, the more widespread the disease
appears in the family. We frequently hear a syphilitic father
say that his wife and children are healthy, but on examination
we rarely fail to find evidence of the disease in the wife and
in one or more of the children.
144 RELATION OF EXPERIMENTAL SYPHILIS TO EUGENICS
THE FITNESS OF PERSONS WHO HAVE BEEN INFECTED FOR
MARRIAGE
When Is a person who has had syphilis fit to marry? In
other words, when is syphilis cured? If either a man or
woman still has syphilis, we cannot safely give consent to mar-
riage, because there is a distinct risk in either case that the
offspring will be infected. We cannot say that this will al-
ways happen, much less can we say that it will not happen.
The chances are all in favor of its occurrence.
Under the older rules, if a syphilitic had had more or less
continuous treatment for one or two years and had shown
no external symptoms for two or three years more, he was
allowed to marry. It has been a great disappointment to find
that a large number of such cases were not really cured and
that they were not really fit for marriage. In fact, in the
light of our modern tests for the presence of the disease, we
have reason to believe that the majority of cases treated in
the most approved way by mercury and potassium iodide were
not really cured ( 4 ). The disappointment over the failure of
salvarsan to produce permanent effects in a small number of
doses does not compare with the disappointment over the fail-
ure of our historical remedy mercury even when given for
years, to really cure the disease in the majority of cases.
At present we have four tests which have been contributed
by experimental and laboratory work for the detection of the
disease. These tests cannot safely be disregarded in determin-
ing the marriageability of persons who have had syphilis.
These are as follows :
1. A series of Wassermann reactions.
2. The provocative Wassermann reaction.
3. The luetin reaction.
4. Examination of the cerebrospinal fluid.
If any of these tests are positive, I believe that consent
should not be given to marriage, because a positive result in
any of these tests, according to our present knowledge, indi-
cates the presence of living parasites. In regard to the Was-
sermann reaction there is a tendency on the part of some clin-
icians to regard a positive result in late cases simply as an
evidence of past infection, like the persistence of the Widal
reaction after typhoid. In my opinion this is an entirely
mistaken view and one full of danger. Everything we know
about this reaction indicates that it is a symptom of the
disease and it should be regarded as such. It is not strange
HENEY J. NICHOLS, M. D. 145
that the other more comfortable view should be held, because,
unless we hold such a view, we are compelled to admit that
the older methods of treatment failed to cure in a majority
of cases and even with salvarsan we are compelled to admit
that some cases are practically incurable. Bnt it is the duty
of scientific medicine to seek and to state the truth and while
the clinician in daily touch with the hopes and fears of the
patient may be inclined to take the easiest route, it is the
duty of the laboratory to stand by the facts as it knows them.
It is not necessary to enter into a detailed discussion of
these tests here, but they should be used to supplement each
other. I have compared the results of the first three tests
in a series of late cases in the following table :
Provocative Luetin
Wassermann reaction Wassermann reaction Reaction
1. + +
2. + +
3. + +
4. + +
5. + 4-
6. -f
7. +
8. +
a +
10. +
11. +
12. +
It is evident that we cannot safely rely on a single test;
we must use all the means at our disposal. We must insist
on a clean bill throughout if practical advance is to be made in
eugenics. The standard here outlined is a severe one and
many candidates will fail to measure up to it, but in view of
the nature of the disease as already outlined, it seems to me
the only safe standard. The requirement of an examination
of the reproductive fluid is probably an impracticable measure,
but it is not out of the bounds of possibility.
On the other hand it would be a great mistake to imagine
that syphilitics are doomed because we find evidence of a
hidden infection in so many cases. "We have good reason to
believe that a majority of the human race have tuberculosis
at some time of life and in most cases without even knowing
it, and syphilis in many respects is no worse than tubercu-
losis. In addition we have means of treatment. We can con-
trol the disease even if we cannot thoroughly eradicate it in
late cases. Many syphilitics do the hardest kind of physical
146 DISCUSSION
and mental work and are fit for all the activities of a useful
citizen with the one exception of the perpetuation of the race.
For this function they should be made to qualify.
In my experience most men, under these circumstances, are
right minded. They are not willing to experiment with human
flesh and blood. They are willing to forego marriage for
the time and entirely if necessary. Of course, there are others
who are not so mindful of duty and they should be forced into
the same position by the combined efforts of parents, physi-
cians, clergymen and general public opinion as seen in the
eugenics movement of today.
REFERENCES
1 Uhlenhuth u. Mulzer, Berl. Klin., Woch., 1913. No. 17.
2 Neisser, Pathologie u. Therapie der Syphilis, 1911. 71.
8 Uhlenhuth u. Mulzer, Arb. a. d. Kais. Gsdhte, 1913. 44 Hft. 3.
* Craig and Nichols, Bulletin No. 3, War Dept., S. G. 0., 1913, p. 130.
DISCUSSION
By a Member: I would like to ask the Doctor's opinion as
to the inoculation of various serums for the prevention of dis-
ease, and as to what he thinks might be attributable to the
inoculation of various toxins and serums. Investigations in
the Agricultural Department show that cattle are shipped
from Michigan to New York with these diseases; and we
think a great deal of what the individual is supposed to be
responsible for is attributable to the inoculation of diseases
from the lower animals.
Dr. Nichols: I can answer this question in the negative
absolutely. I do not believe that the virus of syphilis is trans-
mitted by the injection of any vaccine or toxin. It is a very
fragile organism and will not stand much manipulation. Most
of these vaccines have antiseptics in them and it would not
be possible to transfer the virus in those. In regard to small-
pox, the cow is not susceptible to the disease as far as I know,
certainly not naturally; and it would be difficult for that
virus to get into smallpox vaccine. I have no sympathy with
this criticism or question.
Dr. Leon I. Cole, Madison, Wis, : Our chairman has said that
eugenics deals with heredity. The point that struck me is the
difficulty in distinguishing just what is hereditary. I think Dr.
Nichols very appropriately placed syphilis as a transmissable
disease. I think it was he who said, "A disease that is trans-
RELATION OF EXPERIMENTAL SYPHILIS TO EUGENICS 147
initted before birth, but is not inherited in the strict sense in
the sense that it acts directly upon the germ cell." The border
line, it seems to me, is very indistinct, and this has been
brought out in experiments which have been recently reported.
The general facts have been known to physicians, but such
scattered facts are not readily accepted by biologists because
they lack the proof that can only be obtained from experi-
mentation. I refer to the effects of alcoholism. You are un-
doubtedly familiar with the general effects as observed by the
physician. The effects of alcoholism of the mother upon the
developing child are too obvious to require further remark.
Kecent careful experiments have shown that the alcoholism
of the male in the guinea pig has a very marked effect upon
the offspring produced. Not only are there many cases of
failure of birth, failure to complete the term, but many off-
spring are born dead or die soon after birth; and compara-
tively few are normal. We can understand this because it has
been proved with alcohol taken into the system. Alcohol taken
into the system is soon in the blood and in the reproductive
organs, and it may have a direct effect upon the forming of
spermatozoa. The most interesting thing is that they have
been carried to the second generation, and although these de-
fective young that are produced by alcoholized males are not
treated with alcohol, they nevertheless produce defective
young. Here we have what looks like the true inheritance and
the inheritance of an acquired characteristic. It is the in-
heritance of an effect that has been produced upon the germ
cell. The effect of poisons and diseases as Dr. Nichols said
in the case of syphilis with respect to the sexual glands has
a most far-reaching influence. This line of facts is entirely
distinct from the transmission of the germ of the disease down
through successive generations. Going back to Dr. Daven-
port's paper I think in fairness to him I should interpret his
abstract as meaning to point out merely what was perfectly
obvious from the breeder's point of view, not drawing any
necessary conclusion as to the course events must take in
child conservation or in eugenics. No doubt he is right with
regard to the effects of universal conservation. But there is
the ethical side which cannot be lost sight of. I think this can
be defended as a necessary part of eugenics just as well as that
of obtaining normal healthy offspring. Fortunately, in addi-
tion to any volitional or any differential mortality due to any
cause, there are certain of these things which tend to correct
themselves. This is true in conditions such as alcoholism. In
experiments that have been carried on with rabbits we have
DISCUSSION
found that the alcoholized male decreases his probability of
producing offspring under certain conditions, so it is a hope-
ful sign that we have what may be called compensatory regu-
lation.
Dr, F. W. Pinneo, Newark, N. J. : There are two or three
points in Dr. Jordan's admirable remarks I wish to discuss
briefly. We consider that every baby born has an equal right
to its life with any other; and yet we feel that we have a
racial responsibility. Where is this to be exercised ? Certainly
not upon the individual after birth. He is a living being and
has his rights with the rest of the race. It was to have been
exercised before; it is therefore preventive medicine. We can-
not blame any individual that he was not well born. He had
a right to be well born. Our problem is to elevate the status
of every living human organism, and it may be well to state
that there should be no discrimination among those who were
born. Where is this application of eugenics to be made? It
must be in the limitation of the right of the originally un-
fit to progeny. The first step will be the elimination by those
who are physically unfit. Since some of those diseases for-
merly considered hereditary are now being grouped as infec-
tious they must be viewed from a different standpoint. Tuber-
culosis came under specific treatment when Koch made his
discovery. Syphilis is now viewed as an infectious disease.
We, therefore, consider eugenics in its practical application
as including not only hereditary factors, but environmental
factors also.
TUBERCULOSIS AND HEREDITY
HARRY T. MARSHALL, M. D., University of
Not so very long ago the view prevailed almost univer-
sally that pulmonary tuberculosis was an hereditary disease,
but when Yillemin demonstrated that tuberculosis could be
transmitted by inoculation from one animal to another, and
when from Koch came the announcement of the relation between
the tubercle bacillus and the disease, there was a violent and
immediate change of opinion. The importance of contagion in
the causation of tuberculosis at once assumed so dominant a
position in men's minds that other factors were more or less
overlooked, and with the proof that this is a bacterial disease,
it became clear that the earlier views concerning its hereditary
transmission were erroneous, or, at least, required modification.
Tn fact, doubts were raised as to whether the disease could be
transmitted at all from parent to offspring and the expres-
sion "one is not born tuberculous" came to represent the
opinion prevailing widely in medical circles in spite of an
occasional voice of protest such as that of Baumgarten.
With the rise of tuberculosis campaigns, with the multi-
plication of sanatoria, and of centers for visiting nurses, and
with the increasing intensiveness of research upon tubercu-
lous diseases and tuberculosis problems, it has gradually be-
come evident that infection with the tubercle bacillus is by
no means the only important factor in the production of clin-
ical tuberculosis. We have learned that there are very few
adults who have not received tubercle bacilli into their sys-
tems, and inasmuch as most of us do not suffer clinically from
tuberculosis, it is clear that something more than mere infec-
tion with the bacillus is needed in order that the disease may
develop in an infected person. The study of the etiological
factors additional to infection has received a great deal of
attention during recent years. We know that when large
numbers of tubercle bacteria enter the system, the danger of
becoming diseased is greater than when a few bacteria are
acquired, and we therefore believe that prolonged and intimate
contact with a careless tuberculous subject increases the dan-
ger for the other members of the patient's household. The in-
creased chances both for infection and for repeated infection
149
150 TUBERCULOSIS AND HEREDITY
are supposed in large measure to account for the high rate of
consumption which occurs in "tuberculous families." There
is much evidence to support this view, and there can be little
doubt that prolonged and intimate contact with a careless
consumptive is dangerous. There is, however, a decided tend-
ency evident at present to recede from the prevailing popular
view as to the excessive danger from association with tuber-
culous patients. Tuberculin skin tests have shown that prim-
ary infections usually occur in early life, and there is an
opinion current that symptoms developing even much later are
due to renewed activity of an infection which has lain latent
rather than from a fresh infection. ( See Bartel, Wiener Klin.
Wchnschr. Vol. 6, No. 13, p. 485, 1913 ; Baldwin, Bull, of the
Johns Hopkins Hospital, 1913, Vol. 24, No. 269, p. 224; Pol-
lak, Beitrage z. Klin, der Tuberkulose, 1910-1911, Vol. 18-19,
p. 473.)
In the second place there is some evidence to indicate that
some tubercle bacilli are more virulent than others. Thus
Pollak (Beitrage z. Klin, der Tuberkulose, 1910-1911, Vol. 18-
19, p. 373), found that out of forty-five infants, those dying
of tuberculosis had in the large majority of instances received
their infection from patients with severe or fatal forms of
tuber culosis, while those with milder infections had received
their bacteria from patients with less severe tuberculosis.
In the third place most of us are fully persuaded that the
vitality of the individual is, of all factors, the one which is
most important in determining whether or not the individual
will become tuberculous. The vitality of the individual can
not be greater than is allowed by the original endowment from
his parents or ancestors, but his patrimony may be either
conserved or squandered. Most of us are able, at our best, to
withstand the assaults of the tubercle bacilli which we receive,
and although the vast majority of us harbor the germ at one
time or another we know from numberless examples that the
danger is slight except for those whose vitality becomes con-
siderably depleted. The causes of lowered vitality have thus
come to assume a prominent place in the crusade against
tuberculosis, and many of the more obvious causes have been
recognized and attacked. I need only remind you of the close
relation existing between the tuberculosis crusade and the
great movements to improve housing conditions, work-shop
conditions, factory conditions, etc., and to the compaigns of
education in regard to the dangers of impure air, underfeed-
ing, exposure, alcoholism, and even of worry and of exhaust-
ing hard work, to indicate to you how hydra-headed the tuber-
HAEEY T. MARSHALL, M. D. 151
culosis problem has become since the relation of personal vital-
ity to infection has come to the front
It is probable that none will deny, and few belittle, the
very great importance in the spread of tuberculosis of the
etiological factors just outlined, but it is possible that undue
emphasis may be placed upon them, or, at any rate, that other
factors may be underemphasized. From another source be-
sides those mentioned, evidence has been brought to show that
the danger from contact with tuberculous patients has been
exaggerated. Werner (Beitrage z. der Klin, der Tuberkulose,
1910-1911, Vol. 18-19, p. 355) has studied the mortality sta-
tistics of the rather isolated community, Lippspringe, for the
century from 1801 to 1909. The sanitary conditions in this
community were poor, and from 1833 up to the present, great
numbers of tuberculous patients have visited Lippspringe, re-
siding, until within recent years, in the homes of the inhabi-
tants. In spite of this prolonged contact with tuberculous
patients the death rate from tuberculosis has fallen from
31.2 per cent of the entire death rate in 1831 to 23 per cent
in 1906-1909. Between 1906 and 1909, thirty-five out of every
ten thousand inhabitants died of tuberculosis. He concludes
that the danger from contact is much less than is commonly
supposed, and that the personal disposition or diathesis is of
great importance. Bartel (Med. Klin., 1913, Vol. IX, No. 6,
p. 217) has recently made a study to determine the possible
relationship between an hereditary lymphatic diathesis and a
tuberculous diathesis and his study met with some success.
That there is some relation between structure or function
and a tuberculous tendency seems evident also from numerous
reports which show that young children and adults over 40
years of age are especially selected by tuberculosis, and that
males are much more often attacked than females (See Qrun-
berg, below).
Knopfs observation (Med. Eecord, N. Y., Vol. 83, No. 5,
1913, p. 185) that tuberculosis is commoner among the younger
members of large families than among the children born earl-
ier is along the same direction. It seems then that predis-
position or diathesis deserves more attention than it receives
today. While recognizing that one's vitality may be reduced
by accidents, or by one's manner of living, there is also reason
to believe that not all of us start life with equal powers for
resisting invasion by tubercle bacilli. In other words, some
of us inherit a diminished vital power of resistance for tuber-
culosis. The relation between tuberculosis and heredity has
been approached from three points of view in current medical
152 TUBERCULOSIS AND HEREDITY
literature, and it is claimed that the distribution of tuber-
culosis can not be understood unless the importance of heredi-
tary diathesis is properly appreciated.
CONGENITAL TUBERCULOSIS
Baumgarten has long insisted that in a small proportion
of cases the tubercle bacilli pass from a diseased mother
through the placenta to the foetus, remain latent in the off-
spring often for many years, and eventually give rise to clin-
ical tuberculosis. His theory is not generally accepted as an
explanation of any large number of cases. In a recent review
Harbitz (Miinch. Med. Wchnschr. Vol. 60, No. 14, p. 741, 1913)
claims that hardly more than twenty cases of congenital tuber-
culosis, out of one hundred and twenty which have been
reported, will stand the test of careful criticism. Neverthe-
less recent experimental work by Landouzy and Laederich
(La Eevue internationale de la tuberculose, 1912, Vol. 21, pp.
25-32) shows, first, that tuberculous male guinea pigs are usu-
ally sterile, but the tubercle bacilli are present in their seminal
discharges; second, that tuberculous females may give birth
to tuberculous offspring, and third, that tuberculous offspring
may present none of the clinical features of tuberculosis until
some time after birth. For example, a guinea pig from a tuber-
culous mother was underdeveloped at birth, but appeared
otherwise healthy. It was killed and examined at the age of
three months, and showed definite tuberculous granulations
in the lung. The conditions of experiment were such that
there could be no possibility that the infection arose from the
tuberculous parent after birth. At the same time the same
experimenters found that a much greater proportion of the off-
spring became tuberculous if the young guinea pigs, rabbits,
etc., were allowed to remain with their tuberculous mothers
subsequent to birth. In this connection the high frequency
of tuberculous lesions in the placentas of tuberculous mothers
is to be remembered. It seems to a reader of recent literature
that the possible bearing of Barters "lymphoid stage" of tuber-
culosis upon the problem of congenital tuberculosis has not
been studied as fully as it should be.
PARENTAL TUBERCULOSIS INJURES OFFSPRING
That parental tuberculosis profoundly influences the off-
spring has been shown within recent years. The experiments
of Landouzy, referred to above, were taken by him as strong-
evidence that parental tuberculosis has as baneful an influence
upon the offspring as either syphilis or alcohol. In his cases
HARRY T. MARSHALL, M. D. 153
even the non-tuberculous offspring exhibited a much higher
rate of mortality, the death rate for young guinea pigs, rab-
bits, and dogs from tuberculous mothers being as high as 41.9
per cent of the offspring. In many instances the animal pre-
sented definite anatomical causes for the death, but in a few,
the animal was well developed and healthy looking and there
was no obvious cause for death. The survivors were often be-
low the normal level of weight and the later development,
especially of the young guinea pigs, was retarded, sometimes
permanently. In these instances careful postmortem exam-
inations and inoculations failed to reveal in the offspring evid-
ence of the tubercle bacillus. Some of his cases suggest that
parental tuberculosis may be responsible for cardiovascular
dystrophies in the offspring or for other anatomical dys-
trophies, and occasionally for functional difficulties not asso-
ciated with anatomical change.
Similar to the experimental evidence of Landouzy is the
clinical evidence obtained by Grunberg (H6r6dit6 et Tuber
culose, etc., Thse., Paris, 1912) in a critical analysis of five
hundred and sixty-eight families carried through three genera-
tions. Out of two thousand and five offspring, six hundred
and eight-nine were especially examined for the determination
of any abnormalities. In this very interesting study, Grun-
berg determined the relation between tuberculosis in one or
both parents or in earlier ancestors and the mortality and
morbidity of the offspring. Four hundred and seventy-two
of his families were tuberculous. Of the tuberculous offspring
less than five per cent came from parents free from tuber-
culosis. In other words, over ninety-five per cent of the tuber-
culous offspring had a tuberculous parentage or ancestry. The
frequency of fatal tuberculosis in the offspring ran fairly par-
allel with the degree of relationship between the child and
the tuberculous ancestors. Paternal tuberculosis was appar-
ently as serious as maternal in its effect upon the offspring.
Less than three per cent of his families were afflicted with
non-pulmonary forms of tuberculosis and in these instances
the influence upon offspring was much less than in the pul-
monary forms. It is interesting to note that pleurisies or
tuberculous bronchitis occurring in the parent subsequent to
the birth of the child was associated with little or no danger
to the offspring, while the same diseases in one or both parents
even years before the birth of the child, conferred upon the
child a definitely increased danger either of tuberculosis or
of one of the tuberculous dystrophies. This is not what would
be expected if the parental predisposition were an hereditary
154 TUBERCULOSIS AND HEREDITY
characteristic as the physical attributes are. If acquired char-
acteristics are not inherited, a parental predisposition towards
tuberculosis should be transmitted to the offspring as defi-
nitely by predisposed parents who have not had pleurisy, etc.,
as by those who have been actively tuberculous. If further
evidence supports Grunberg's observations in this regard, the
presumption will be strengthened that tuberculous predis-
position in the offspring is not truly an hereditary character-
istic, but is due to the fact that the parental reproductive cells
were rendered abnormal by the direct action of the tubercu-
lous process in the parent.
In addition to a high increase in the death rate from tuber-
culosis among offspring of tuberculous families, Grunberg
shows that there is also a high increase in the death rate of
infants and of the young from other causes than tuberculosis,
especially from non-tuberculous, pulmonary infections. More-
over the offspring are peculiarly apt to suffer even in later
life from maldevelopment, anemia, cardiovascular disease and
nervous troubles. Even the offspring who do not manifest clin-
ical tuberculosis show a much higher percentage, age for age,
of positive von Pirquet reactions.
From Grunberg's study it seems fairly clear, first, that tuber
culosis is very much more apt to occur in a person, one or
more of whose ancestors or parents suffered from pulmonary
tuberculosis and that the chances of acquiring tuberculosis
are greater in proportion to the numbers of ancestors who
were tuberculous, and the nearer the relationship. Second,
that pulmonary tuberculosis in ancestors is much more seri-
ous for the offspring than non-pulmonary tuberculosis. Third,
that tuberculosis in parents and to a less degree in ancestors,
greatly reduces vitality of even the non-tuberculous offspring,
so that while their birth rate is higher, their infantile death
rate is much higher and dystrophies and cases of under-de-
velopment are frequent among them.
TUBERCULOSIS AND PHYSICAL DETERIORATION
A point of view differing from that of Baumgarten, and
equally from that of Landouzy and Grunberg, is advanced by
Karl Pearson, of London (Tuberculosis, Heredity, ancl En-
vironment, Dulau Co., London, 1912). The main point that
Pearson makes is that taking into account the whole sub-
ject of tuberculosis and allowing that infection is almost uni-
versal, it must, nevertheless, be recognized that tuberculosis
does actually follow the lines of heredity. Everybody being
HABRY T. MARSHALL, M. D. 155
exposed to tuberculosis, tliat is, receiving doses of the germ
from time to time, only tliose become 'tuberculous in whom
there is the hereditary predisposition. He compares the
heredity of different physical characters with the apparent
heredity in tuberculosis and concludes that the two sets of
phenomena follow the same laws and are therefore most logic-
ally explained on the same ground. He finally concludes that
tuberculosis most prominently affects those families which he
would rank as physically unfit. While not denying that other-
wise healthy individuals may become tuberculous, the great
majority of fatal cases, according to him, occur in families
presenting some one or more stigmata of deterioration. Pear-
son has not shown, however, that inferior resisting power
against tuberculosis is incompatible with the possession of
other attributes which are of very great value to humanity.
We need not enter into a detailed consideration of the con-
clusions which Pearson draws with regard to the modern war-
fare upon tuberculosis, but I will merely emphasize the fact
that Pearson considers that tuberculosis is especially apt to
attack an already inferior family stock, while Landouzy and
Grunberg indicate that the tuberculous process itself produces
inferiority of the stock in generations subsequent to the orig-
inal infection.
I have endeavored in this paper to place before you a brief
account of those aspects of tuberculosis investigation which
are most closely related to eugenics and heredity. Pearson,
Landouzy and Grunberg have introduced into the study of
tuberculosis new methods which should lead to important ad-
vances in our knowledge -of tuberculosis, and which should
induce us to study this subject not only from the medical,
the sanitarian, and sociologic points of view, but from the
broadest biologic standpoint. It is possible that the newer
studies may eventually lead to a modification in the attack
upon tuberculosis. If the opinion should become established
that families presenting a high tuberculous mortality owe this
high death rate to the disastrous results of infection and en-
vironment, the activities of philanthropists would certainly be
turned in a different direction from that which would be pur-
sued if the theory should prevail that the tuberculous fam-
ilies are, as Pearson maintains, fundamentally inferior, and
that they should be discouraged from propagation.
On the whole, work such as that of Landouzy and of Grun-
berg impresses one greatly with the idea that the tubercle
bacillus is disastrous far beyond its direct infections and one
is inclined to withhold acquiescence in the views of Pearson
156 TUBERCULOSIS AND HEREDITY
until further and stronger evidence is brought forward in
suport of Ms hypothesis. Eecent work tends rather to indi-
cate that a modified form of inheritance is of importance in ac-
counting for the increased susceptibility of offspring of tuber-
culous parents for tuberculosis, but it still seems to be doubt-
ful whether this is a true family inheritance, which will be
transmitted from generation to generation. Eosenau and And-
erson (U. S. Hygienic Laboratory, Bull. No. 36, 1907, and No.
45, 1908) showed that if female animals were rendered hyper -
susceptible to proteids or bacterial substances as the result of
inoculations, the offspring of these females were also hyper-
susceptible. Krause (Bull, of the Johns Hopkins Hospital,
1911, XXII, No. 245, p. 249) and Austrian (Bull, of the Johns
Hopkins Hospital, 1913, XXIV, No. 267, p. 141) have taken
this matter up with regard to one of the products of the tuber-
cle bacillus, and their very interesting experiments show that
the offspring of sensitized animals are also sensitive. It seems
possible that this has an important bearing upon the apparent
inheritance of a sensitiveness for tuberculosis in the offspring
of tuberculous mothers, and it may well be proved that when
the parent has been sensitized with tubercle bacilli the offspring
will be sensitized exactly as when the sensitizer is tuberculo-
protein. Eecent work upon anaphylaxis shows the close re-
lationship between anaphylaxis and infection. While it is
still far from being a matter of demonstration it will not be
surprising if future investigations should bring to light some
necessary inter-relationship between sensitization through in-
fection with the tubercle bacillus and hyper-susceptibility of
the offspring towards the same organism.
DISCUSSION
Dr. Paul Paquin, Asheville, N. C. : This most excellent paper
by Dr. Marshall is so comprehensive in its text and its sugges-
tions of scientific and practical nature that in its discussion
one can scarcely touch even the high points, and to touch these
is a task of hours even for the best informed. So, I will limit
my remarks almost entirely to some of the questions raised in
his first propositions.
We read there and we learn now from the able presentment
of Dr. Marshall something about the tendencies to determine
tuberculous infection and to arrest the tuberculous processes
by considering the condition of the patient.
Kegarding "Infant Mortality" this brings us face to face
with the question which I have designated as the "Border-
DISCUSSION 157
land of Tuberculosis/' that condition in which a child is not
yet actively tubercular but on the frontier. It is a stage of
childhood which can be surveyed in due time and with suffi-
cient accuracy to afford those involved prophylactic measures,
more or less effective, early enough to save life at least, and
generally to lay the foundation for endurance and good health,
if not indeed, immunization against tuberculosis, than which
affliction perhaps none destroy more lives.
Of the four curses which are tearing down the body and
soul of the white man: war, leutic affections (I include here
syphilis and gonorrhea) ; alcoholism; tuberculosis; all leaving
in their respective paths wreckage of brains, morals and
bodies, maybe tuberculosis is not the worst, but surely it is the
most prevalent disease of a ruinous nature, affecting about
80 per cent of the white people of the earth, incapacitating more
or less about 10 per cent and consigning to the grave prema-
turely not less than 6 per cent every year.
Among the physical signs of the "Borderland of Tubercu-
losis" ixi children are to be noted in particular ; fitful and capri-
cious appetite, irregularity of the nature of the stool with
fever and pains, intestinal, stasis, particularly the colon, fre-
quent colitis a very mean factor indicanuria, habitual head-
aches, frequent nose-bleed, early and excessive brightness of
intellect, recurrent tonsilitis, adenites in various localities, las-
situde without undue exertion, frequent listlessness, seeming
indifferent to duties (often when at heart desirous of per-
forming them), over activity of hair growth, irregular stom-
achal and intestinal dyspepsia, pale and pinched features, dis-
inclination to play,' inclination to inactivity, occasional flush-
ing of the cheeks, unaccountable subnormal temperature (more
common in the morning), pleurisy, occasional aching in one
or more identical spots in the front or back of the chest
more usually in the upper third, under the shoulder blades and
at the base of the lung, hypertrophied tonsils, adenoids, lymp-
hoid growths of the throat, hacking coughs with or without
expectoration, grayish glairy sputum (even in small specks),
spitting of blood, even in minute quantities; habitual scrap-
ing of the throat, chronic respiratory catarrh, sweating with-
out natural causes (night or day, general or localized), habit-
ually or irregularly fast pulse, clammy or sweating hands or
feet, susceptibility to colds under slight provocation, certain
abnormal chest conformations and deficiencies, as contractions
and dented muscles between the ribs ; slim and flabby muscles,
dry skin, respiratory restrictions, lung inelasticity, reduced
expansions, abnormal breathing, short breathing, etc. I have
158 TUBERCULOSIS AND HEREDITY
given these irrespective of order. Pei'haps none of these indi-
cate tuberculosis positively, but all, separately, and groups of
them in particular give warnings which should be heeded.
These symptoms and the special diagnostic tests cover three
questions : First, whether or not the system is merely fit soil
for the tubercle bacilli and other germs which follow them;
second, whether any of these parasites have already begun their
growth without suggestive external manifestations; third,
whether or not tuberculosis activity exists in any degree.
The physical examination and other analyses of the sort to
decipher the symptoms should be complete and as a rule pre-
cede the specific steps.
Having determined the "Borderland of Tuberculosis" the
next step is to apply prophylactic remedies. What are they?
First. Suitable cellular nutrition the foundation of nat-
ural resistance to disease.
Second. Immunization. I will not dwell on nutrition or
its problems, but pass on at once to the questions of immun-
ity, about which Dr. Marshall also spoke most interestingly
and usefully.
Since the vast majority of civilized humans harbor the
tubercle bacilli in their system and only comparatively few
succumb to them, there must be in the body of man some
forces to destroy these germs, or to neutralize their poisonous
effects or at least hold them in check. These forces are they
which the interested scientists of the world are trying to
harness by vaccinating human beings against tuberculosis.
There have been recognized as immunizing bodies, certain
sera and tuberculin agents, whose action is expected to be
bacteriolitic, that is, capable of dissolving tuberculin bacilli
in vivo. The latest of these brought out seems to be that of
Von Buck, which he calls a vaccine, and which he has used,
it seems, lavishly on several hundred children and on early
cases of tuberculosis with effective results. He and Dr. Julian,
of Thomasville, N. 0., claim to have vaccinated successfully in
the last two or three years not less than four hundred young
individuals.
In these cases Dr. Von Euck claims, and illustrates his posi-
tion by micro-photographs and prints, that he has, by one
to three or four injections of a tuberculin vaccine caused his
children's and patients' blood to become lytic to the bacillus,
that is, that the serum in the blood dissolves the tubercle germ
and that therefore they cannot live in it.
Now, ladies and gentlemen, needless to say that if we
had as effective a vaccine against tuberculosis as against small-
DISCUSSION 159
pox and it were applied generally in infancy, we could soon
master the disease absolutely. It appears to me therefore that
the association should investigate the claims of those who
say that they can immunize human beings against tuberculosis,
so that, if found true, humanity shall be in a position to be
benefited, and. if false, the facts should be published broad-
cast.
THE EDUCATION OF PARENTS IN PRACTICAL EUGENICS A
FACTOR IN THE PREVENTION OF INFANT MORTALITY
EVANGELINE WILSON YOUNG, M. D., School of Eugenics, Boston
Galton's definition of eugenic makes this science more in-
clusive than would some of his disciples who would limit the
use of the term to heredity alone in the technical interpreta-
tion of the word. It is quite clear that the founder of this
science in thinking of its practical application to humanity
intended to include in his definition certain environmental fac-
tors* The term practical eugenics, therefore, is used to cover
that twilight zone where heredity and environment meet and
where these two factors are not clearly differentiated in the
minds of those who are untrained in scientific niceties. Theo-
retically, heredity and environment are absolutely separable,
but in a working program adapted to popular needs of parents
it is expedient that we ignore fine distinctions in the use of
terms, and make the subject as vital and practical to every-
day human experience as we can.
The average intelligent parent in America today is inter-
ested in eugenics. He wishes to be informed about it, espe-
cially in regard to its human import. If we attempt to satisfy
this interest in terms of guinea-pig algebra, he will have no-
thing of it. This we cannot afford to do, for this average intel-
ligent parent, by the way, is the medium through which
eugenic ideals are to be realized, if at all, and we need his co-
operation and good will; so we must not make the subject too
technical for him to understand. Practical eugenics, then, for
parents, must include instruction in the truths of both hered-
ity and environment. Obviously, men and women already
mated, and in the stress of the cares of bringing up children
already born, need instruction chiefly with regard to environ-
mental factors as they may determine the health and develop-
ment of their children. Where the size of such a family is
already as great as can be properly provided for in accordance
with the family income and the strength of the mother, there
is need for instructing the parents as to the social misfortune
of any further increase when it means certain neglect or lack
of proper nutrition, supervision, or education of the children
already born, and the disability from over-work of parents
already exerting themselves to the limits of efficiency in meet-
160
BVANGELINE WILSON YOUNG, M. D. 161
ing the responsibilities imposed by the already existing family.
I know of no more pathetic situation than that of a woman
who, when asked about the size of her family, remarked, "I
have had ten children, and buried five of them." Once we
wotdd have condoned with her in her losses, but today we are
inclined to think to ourselves, "What a wicked waste a waste
of human strength and energy, to say nothing of the economic
waste through illness and death !"
A lecturer recently stated in a discussion on the size of
families that two children are as many as can properly be
reared by the New England family of average income, and that
any in excess of two is a luxury a luxury to be indulged in
only in cases where the family income warrants it. Such a
dogmatic statement, of course, should not be accepted literally,
but at the same time it is a good proposition to bring to the
attention of the man of average income.
It is not easy to change the ideals of adults whose life-
habits are already well established, but usually an appeal can
be made when the welfare of their children is involved. It is
in this way, chiefly, that we hope to establish a higher code of
eugenic ideals. The boys and girls of today will soon take
their places as the parents of the coming generation, and we
should waste no time in making available to them the dis-
coveries of scientists who have worked out for the human
race the laws bearing upon its future welfare.
To this end, we must educate our young people, boys and
girls, by precept and example, to look upon their bodies as a
valuable possession, as a wonderfully intricate and sensitive
mechanism, which requires the same care for its well-being
as any other delicate machine. This education must include
instruction in the general laws of personal hygiene, includ-
ing the proper kinds of clothing, food, water, and air. They
should be taught the need for exercise and recreation, and
especially the difference between the use and the abuse of these
interests. Especially should they be taught the poisonous
results from fatigue, and the necessity for sufficient sleep. All
these things are so trite that one hesitates to repeat them, but
in how few homes are those simplest rules of health either
taught or observed !
In order to prepare the young woman for motherhood, it
is imperative that she should be taught very definitely and
explicitly her function as a woman, a wife, and a mother.
This necessitates a knowledge of menstruation, of the marital
duties imposed by marriage, and the processes by which new
life originates within her body. In all these subjects the young
162 EDUCATION OF PARENTS IN PRACTICAL EUGENICS
woman today is woefully ignorant. After her wedding day her
sources of instruction are these :
(1) Her husband, whose sexual knowledge is usually found-
ed on the most unscientific traditions which have been handed
down from a far-away past.
(2) Her married friends, as ignorant as herself, whose sex
experiences have been so varied as to furnish no safe stan-
dards.
(3) Experience, as time passes, a sad and costly source of
instruction, and often futile because of lack of intelligent inter-
pretation.
When I realize the ignorance of the average woman in sexual
matters (and in a woman who may otherwise be very intel-
ligent), I do not wonder that so many women look upon ma-
ternity as a shame, or a misfortune, or a nuisance, to be
avoided, if possible, by abortion or by some means of preven-
tion. I do not wonder that the children of these ignorant and
misguided mothers are puny and liable to early death. Some
years ago a friend of mine, a young woman who had lost all
her near relatives, was about to marry. She was a well educa-
ted woman according to present-day ideals, but was densely
ignorant of the facts about married life. She was intelligent
enough, be it said, to know that she was ignorant in these
matters. Having no near friends to whom she could go for help,
she sought information from a physician, thinking that this
was her -best source of accurate information. The physician
refused to give her any information, and stated that "her hus-
band would tell her all that she needed to know !" When she
contemplated the fact that the man whom she was about to
marry had never before had any married experience, sup-
posedly, she was led to wonder where he had acquired the
knowledge which was to be sufficient for them both.
It is the right of every normal girl that she should know
something of the beauty and the glory of her potential mother-
hood, and the right kind of instruction should be given her so
that she may go into married life with joyful expectancy in-
stead of dread, and that she may have a life which is rich and
happy in the fulfillment of this high destiny. Instruction in
practical eugenics does this for her. It teaches her the neces-
sity for choosing wisely in the matter of a father for her chil-
dren. I predict that in the very near future society will grant
to the woman the initiative in this matter much oftener than
at present. The leaven of practical eugenics already indicates
this, and many young women today, not waiting for tardy leg-
EVANGELINE WILSON YOUNG, M. D. , 163
islation to protect them, are requiring directly from the men
who seek them in marriage the proofs of their physical fitness
for this relationship.
The boy approaching manhood and the duties and the privi-
lege of man ? husband, and father, is no better prepared than
the average girl. True, he is not so ignorant of sexual mat-
ters as she, but unfortunately his knowledge is of such a nature
that it is of no benefit to him. On the day of his marriage,
the young man's sex knowledge consists, usually, of a sorry
hodge-podge of shameful sex experience with low women, on
a background of the prevailing false traditions regarding the
woman's inferiority to man, and with a conviction of his
"right" to use the woman's body to any limit that his sexual
passion may dictate. Sexual desire, to him, is an overwhelm-
ing bodily appetite which must be satisfied, if possible, and it
is nothing else. This he has been taught from boyhood up by
both example and precept. The fact that it is often an arti-
ficially stimulated and over-indulged habit is not realized
even remotely by him. The idea of controlling it by the de-
velopment of his will or the possibility of sublimating it, or
of transmuting it into other channels of expression in his
physical or intellectual life, is rarely taught him. In only a
few instances has he learned to think of this appetite as a force
given to all living organisms primarily for the purpose of pro-
creation.
Education in practical eugenics for boys must furnish them
with an entirely new sexual code. Boys need to be taught
quite as explicitly as girls, the spiritual significance of mar-
riage, and the sacredness of the institution of the family. Boys
must be taught that the double standard of morality as now
practiced by men makes the marriage vows of the man a hypo-
crisy that the twentieth century woman will no longer tolerate.
Above all, boys must be taught to respect all women as poten-
tial mothers, so that it shall be an ethical impossibility for any
man to offer any woman money in exchange for the physical
symbol of love. This, far more than all legislation, will help
rid society of the great curse, prostitution.
The results of such education should be development in
the young man of a sense of his responsibility toward his off-
spring; it should protect him in a large measure from the
venereal diseases ; it should give him a control over his sexual
appetite; and it should place the human sex relation upon a
higher plane than has ever yet been realized.
In my experience as a practicing physician and a teacher of
hygiene I find young people entering marriage poorly pre-
164 EDUCATION OP PARENTS IN PRACTICAL EUGENICS
pared for the experience. They are all at sea with no chart
to guide them but the blind, dead-reckonings of others who
have groped through fogs of untruth and half-truth of which
their sex knowledge consists. This ought not to be. The
wonder is not that so many of their children die in infancy;
the wonder is that so many of them "pull through."
DISCUSSION
Prof. Koswell H, Johnson, Pittsburgh : We, of this section,
have quite generally agreed in our earlier sessions that the
workers for prevention of infant mortality are justified in
their indiscriminate efforts, provided only that efforts are also
being made to prevent the production of inferior stocks.
The methods of segregation and sterilization are each im-
portant in dealing with certain classes of the markedly in-
ferior. But these are not the only infants whose birth would
better not be. There is one class most of which could be elim-
inated by a mere change of attitude and laws on one subject.
I refer to the undesired infant.
Infants may be divided into two classes; (1) those whose
conception was desired or at least received with indifference;
(2) those whose conception was not welcomed, even though
at birth the attitude was more receptive. This latter class is
by no means all illegitimate, in fact only a small fraction of
the total number of undesired children in this country are
constituted by the illegitimate, as I am assured by many in
a position to know.
Now we are concerned with a comparison of these desired
infants and the undesired as to their viability and their eugenic
equality.
The greater viability of the desired infants must follow for
these reasons: (1) They have not been impaired by unsuc-
cessful attempts at abortion during the intra-uterine life.
(2) They are less likely to be born of parents who know
themselves to be of defective or objectionably abnormal nature.
(3) They are less likely to be conceived and born during a
period of temporary inferior state of health. (4) They are
less likely to be born following too closely the previous preg-
nancy or lactation. (5) They are less likely to be born while
parents are infected with venereal disease, and (6) especially
because they will receive more devoted care.
The eugenic quality of the desired infant is better because
in many cases the desire is actuated by (1) the normal and
socially useful instinct of parenthood (by which I mean some-
DISCUSSION 165
thing different from that of sex) and (2) by a sense of the
need of contributing to the next generation or (3) by the
longsightedness involved in foreseeing the advantages of chil-
dren to the parents as the parents grow older.
There are two methods of decreasing the number of un-
desired children, (1) by urging more sexual abstinence in mar-
riage; (2) by the relaxation of the present interdiction of the
spread of knowledge or materials used in the limitation of
the family and a corresponding change in attitude. An addi-
tional reason for greater publicity in this matter is to discrim-
inate in this field and so prevent some of the methods employed
in ignorance of the whole subject which are distinctly in-
jurious.
The situation at present is that well-informed persons are
limiting their families as demonstrated by Sydney Webb's
illuminating investigation, while the unwelcome children are
disproportionately contributed by the ignorant.
A fear that has been expressed is that such knowledge and
practice might depress the birth rate so seriously as to be a
menace to the population of the future. As to this it would
not be easy to decide, where on one side there is better quality
with a stationary or a possibly slightly declining population
for a while or an increase of our numbers by inferior contribu-
tions. An ambitious generation will surely work on hopefully
for a better man.
Mrs. William Lowell Putnam: It is a pleasure to say that I
agree absolutely with all that Dr. Johnson has said. In Buf-
falo, at the Sex Federation Meeting held at the recent Inter-
national Congress on School Hygiene, all of the men who spoke
took the blame of the present unfortunate state of affairs upon
themselves, and all of the women joined in and put it upon
them. I am very weary of this sort of talk from women. I
also take exception to Mrs. Hammond's statement that women
have been the upholders of the purity of the race. My own
belief is that each sex is what the other has demanded of it
If women are purer than men it is because men have demanded
purity of their women. Women have not demanded purity of
men. It is for them to do so, for if they demand it they will
get it. Women have the future of the race in their keeping.
Dr. Hastings H. Hart, New York: We are recognizing the
plight of the feeble-minded girl, the most urgent problem
before us. Dr. H. H. Goddard says that a feeble-minded
166 EDUCATION OF PARENTS IN PRACTICAL EUGENICS
girl is three times as dangerous to a community as a feeble-
minded boy. A normal woman will not ordinarily consort
with a feeble-minded man, but a normal man will consort with
a feeble-minded girl. If any man in the community offers an
indignity to a feeble-minded child, every right-minded man
of the community arises to the defense of that child. The
feeble-minded girl of sixteen is in stature and physical in-
stincts a woman, but in mentality and will power she is a
child of six or seven years, and entitled to the same chivalric
protection as her little sister, and even more, because owing
to her situation and stature and development she is in more
danger than a little child. She is pursued and destroyed like
a rabbit, and regarded as a common prey to the reckless and
thoughtless men of the community. When she goes wrong we
lock her up and send her to a reformatory. From 25 to 50 per
cent of wayward girls are upon examination found to be feeble-
minded. We proceed to teach and train and admonish her and
after a little she is sent out on trial and she gets into trouble
again. Institution people are absolutely forced to send these
girls out because we have not provided care for them. We pro-
vide care for the insane women who are not half as dangerous
to the community. When this feeble-minded girl falls into trou-
ble again she is labeled as a vicious person, a repeater; she is
an outcast, despised, and she goes to jail. She will corrupt
fifteen or twenty boys in a community, and infect them with
disease. She becomes a mother of defectives, and the result is
we are reaping a harvest that is incalculable. Why does a
community take care of the insane woman and not of the
feeble-minded? It is because of the superstition that the
insane are dangerous; but the feeble-minded woman is three
times more dangerous than the insane woman. We should get
every woman of this class in every almshouse or reform school
and have this question adjudicated and these women taken
care of, at least during the child-bearing age. I am not op-
posed to sterilization, but it is absolutely futile. It does not
prevent the spread of disease. We must do with the feeble-
minded girl what we have done with the insane woman, that is
segregate her. We are doing it with seventy-five thousand
insane, and yet we say the expense is so great we cannot af-
ford to segregate the feeble-minded women. We must also
segregate the high-grade imbeciles, because they populate our
houses of prostitution on one hand and on the other hand
they perpetuate their kind.
DISCUSSION 167
Dr. Helen C. Putnam: Will you go one step farther and tell
us what we should do with the feeble-minded man who has
political power and social power in the community?
Dr. Hart: He should also be segregated, but I should segre-
gate the feeble-minded women first, because they are the most
dangerous. We are building schools for feeble-minded chil-
dren, and gathering up these little children five and six years
old and instituting an expensive method of educating them.
My plan would be to close the door of every institution for
feeble-minded children under twelve, and disregard every
feeble-minded boy or young man until we have taken care of
the feeble-minded girls and young women, and in the mean-
time I would press as rapidly as possible toward the segrega-
tion of the male also. You have sterilization in fourteen
states, but in how many is it practically operated? It will
never prove as effective as segregation so far as making inroads
on feeble-mindedness is concerned.
Dr. Cressy L. Wilbur, Washington: This association stands
for vital statistics so that we may cast light on these disputed
points. I am heartily in sympathy with these eugenic matters.
The building up of a better race by the methods of selection,
and prevention of generation by defectives or degenerates, is
going to be very effective. It will begin with the higher
class, the better educated, those who are conscious of their
defects ; a'nd for a long time to come it will not permeate the
lower levels of society. Hence it would seem that for a time
it might tend to accentuate the proportion of defects in the
community. Perhaps in the higher races it will bring us to
the point where our increase as compared with the lower races
will be jeopardized, and we will cease to hold controlling power
with those where the natural increase proceeds unchecked.
And although we may have a higher quality, if we have not
sufficient numbers to perpetuate the race, we must go under
in the struggle for existence.
Prof. Roswell Johnson, Pittsburgh : I move that a committee
of three be appointed to confer with the Executive Committee
of the Eugenic Section of the American Breeders' Association
as to the advisability of forming a new National Eugenic
Society as recommended by Mrs. John Hays Hammond; this
168 EDUCATION OF PARENTS IN PRACTICAL EUGENICS
committee of three to prepare a resolution to be submitted to
the general committee on resolutions, such resolution favoring
a Federal Bureau of Public Health.
Seconded and carried.
The chairman apointed as such committee the following :
NATIONAL COMMITTEE ON EUGENICS
Dr. F. W. Pinneo
Dr. Evangeline W. Young
Dr. Roswell Johnson
NATIONAL PUERICUJLTURE
ANTONIO VIDAJL, M. .,; Chief of tne School, Industrial and Social
Hygiene Service, National Department of Public Health;
President Argentine Pnfolic Hygiene Society;
Delegate from tlie Government; Buenos
Aires, Argentine RepnT>lic
Mr. President, Ladies and G-entlemen:
Permit me to express my most heartfelt thanks for the invi-
tation to attend and take part in the sessions of this meeting.
I particularly appreciate this attention, not merely because of
the honor involved, but also because it gives me the opportunity
of expressing to this distinguished gathering a few ideas on
matters of pressing importance and positive social significance.
The cause of childhood suffers much from the effect of un-
favorable influences which we know today are in a large degree
preventable. It is not merely a noble cause; it is more useful
than any other, since one cannot help observing that in the
intelligent and far-seeing care of the child are based the most
definite factors of social advancement.
The two great statistical-social phenomena are becoming
each day more clearly elucidated ; these are high infantile mor-
tality and low birth rate. As regards the former, statistics
keep* showing us the heavy tribute of life which tender infancy
is everywhere yielding. But if this is true it is likewise true
that the proportion is being reduced, notably in those groups
where unhealthy influences may be avoided and where a healthy
physique can be built up. Indifference, ignorance and poverty
or lack of resources the three predominating causes are being
obviated, thanks to well-inspired social work. As regards the
diminution of births, we face a real social disease, which in-
creases, as is known, inflicting populations of the greatest
culture. Here we cannot in most cases fall back on ignorance
or lack of skill; on the contrary, we often find knowledge
poorly used.
Preventive medicine and social hygiene lend to eugenics its
greatest resources. There is no doubt that the purposes of this
latter and those of the hygienist are common in many respects.
In other situations, the views of biological and sociological
economics necessarily prevail tendencies toward the slow
169
170 NATIONAL PUERICULTURE
formation of character, toward the gradual accumulation of
hereditary traits; and finally, in some situations divergent
and even contrary tendencies show themselves. The hygienist
because of the finality and ethics of his profession, protects
and prolongs in their functional integrity, existences which go
more or less contrary to the views of the eugenist. It is some-
what difficult to show how these divergencies can be reconciled,
but for the present, I would merely suggest the following:
1st. That as regards today, infancy and its preservation con-
stitute the newest and most varied field of application as well
as the most promising of the two sciences of hygiene and
eugenics ;
2nd. That it seems as if a progressive puericulture, a eugenic
and national puericulture were about to be founded. (The
term puericulture, commonly used in the Latin countries, is
suitable for many phases of the matter, when applied in a
broad sense, such as it is beginning to enjoy, and which its
etymological composition allows.) A national and eugenic
puericulture is desirable I think for all countries, but espe-
cially for all those receiving large accessions by way of immi-
gration, such as is the case with the United States and Argen-
tina.
In almost all European countries activities in the interest of
childhood are being carried on with an extraordinary ardor.
It would almost seem as if they were trying to make up for lost-
time. A lively emulation, a splendid competition are noted
between cities and nations as regards this kind of work. A
conviction seems to have suddenly penetrated the minds of all,
that these undertakings embrace the foresight and progress
of a community, of whose public culture they are really an
index.
A few months ago it gave me great pleasure to witness per-
sonally such activity. My country having charged me with the
mission of studying in Europe, institutions dealing with child-
hood, I had the opportunity of making direct and compara-
tive observations. I have recorded my observations and I am
preparing to apply the material so obtained as a means of
arousing similar activities in my own country.
In France, Germany, England, Belgium, Switzerland, Hol-
land and Italy the movement is very active and productive.
In almost all of these countries foundations have been laid
which have certain traits in common. In France and Germany
the movement is being carried out with the most ample and
vigorous impulses. France, it is true, is crippled by that
ANTONIO VIDAL, M. D. 171
enemy of her prosperity, an internal enemy, the most terrible of
all: the low birth rate, the relative or absolute depopulation.
It is not strange, therefore that the forces of society are united
in the strongest measures of conservation. And there is no
better than the establishment of a high standard of child
hygiene.
I do not intend to present even an incomplete sketch of the
work in France. In addition to the well-known "Gouttes de
Lait" there are the "Pouponnieres" and the "Odches" making
a system; the "Consultations de ^ourissons" the asylums and
hospitals of many kinds; the work of the "Enf ants *Assistes ;"
the beneficial societies, etc. The oldest and most noteworthy
for many reasons of these institutions devoted to puericulture
is that at Porchefontaine, near Versailles, which Madame Veil-
Picardy and Dr. Rairnondi conduct. In this latter institution
and in many others a varied system of maternity education is
given, to which among others, Professor Pinard/Marfan. Hut-
inel, Variot and Mery have consecrated their efforts. At the
head of the numerous and useful societies there is the vast
"French Association for Fighting Infantile Mortality" and
guiding all is the series of progressive laws which the late
glorious spirit Th6ophile Roussel initiated.
The movement in Germany, none the less important, presents
many similar traits. This is explained by their similarity of
purpose. The hospitals and clinics for children at the breast
are particularly noteworthy, as are also the latest equipments
for the preparation and distribution of pure milk for children.
The instruction given to mothers and nurses supplements these
varied 'forms of activity, and on a higher plane entirely de-
voted to physiology, pathology and hygiene we find the Sang-
lingsalters." The excellence of this higher medical instruc-
tion and its marked scientific methods is almost the dom-
inant note in the German movement. Heubner, Epstein,
Finkelmann, Dietrich, Schlossmann, Keller and many oth-
ers have contributed to its success.
At the head of all institutions in its importance, its costly
equipment and its character is the "Kaiserin Augusta Victoria
Haus zur JBekampfung der Sauglingssterblichkeit im Deutschen
Reiche," named in honor of the Empress. It is situated in
Oharlottenburg and is directed by Professor Langstein. Lab-
oratories, clinics, experiment and study have reached their
highest perfection here. As regards the legislative aspect, we
all know what stage legislation protecting childhood has
reached in Germany. There are as many associations as their
172 NATIONAL PUERICULTURB
aims are varied, and above all, likewise founded several years
ago, is a vast national organization, with, local committees in
all titles of the first and second-class importance.
Coming from Europe to America we arrive at your great
and beautiful country. When my investigations in Europe
were over, I saw at once that my studies would have a serious
defect, if I could not include in them first-hand knowledge of
the activities in your own country. You can therefore under-
stand the joy with which I addressed myself to the work of
personally studying the great movement that is being carried
on here. The inspirations I have received are powerful and
most beneficial. The establishments which here, as in Eng-
land, have the same aims as the "Drops of Milk" organizations
in other countries, have an amazing diffusion and perfec-
tion. There is one activity, in particular, which has become
widespread among you, and which is of the greatest impor-
tance. It is the "Visiting Nurse Movement." Better results
can be obtained from teaching mothers directly in their own
homes, than in any other way, and the immediate change in
the health of the babies can also be noted. Through the devel-
opment of this system, I think you will not merely be able
to equal, but also to improve notably in several ways upon
the "Consultations des Nourissons."
Concerning the institutions and work of Child Hygiene in
the Argentine Republic, allow me to indicate the lines we
have traced for our future growth. The first is the establish-
ment of higher education which shall be at one and the same
time, medical, biological and social. The other is the crea-
tion and organization of an advanced Institute of Puericul-
ture, embodying the best now existing in other institutions
and containing also the equipment and means for experimen-
tal studies. When my country shall have finished this plan
of expansion in Puericulture, I am sure that it will borrow
much from your institutions. As the work in Argentine is
inspired by yours, both progress toward scientific truth. Both
take as their watchword the good motto of the International
Union for the Protection of Early Childhood : Parvulis Scien-
tia Praesictio.
SESSION ON OBSTETRICS
Saturday, November 15, 2.3O P. M.
CHAIRMAN
I>R. MARY SHERWOOD, Baltimore
SECRETARY
DR. JAMES LIXCOL.X HTJXTINGTO^, Boston
STATEMENT BY THE CHAIRMAN:
Since the intelligence as well as the physical condition of
the mother is a factor of great importance in the production
and rearing of vigorous offspring, that scheme of conservation
of infant life will be most effective which includes not only
provision for advice and instruction of the expectant mother
during the whole period of gestation, hut adequate care during
confinement.
The program of the Session on Obstetrics will include:
1. A discussion of the scope of prenatal work, its medical
and social aspects, its necessary place in a plan for
the elevation of the standards of obstetrical work in
America.
2. A consideration of the out-patient department of the
obstetrical clinic, in which provision is made for at-
tendance upon a large class of maternity cases whose
circumstances or whose inclination exclude them
from the maternity hospital.
3. A consideration of maternity hospital care for the
woman of moderate means.
4. Reports.
173
PRENATAL CARE
HENRY SCHWARZ, M. D,, St. Louis, Mo.
In its wider scope prenatal care should give to the unborn
child a reasonable assurance that it will be well born and that
it will get a fair start in life by preventing the marriage of
men and women who are physically, morally or mentally un-
fit for becoming fathers or mothers, and by doing, besides, all
that which constitutes "Prenatal Care" in the limited sense
in which we are to consider it this afternoon.
In this limited sense the unborn child is cared for by
watching over the health and the comfort of the expectant
mother; by preparing her for her maternal duties, especially
for the duty of nursing her child and by making adequate
provision for the safety of mother and child during delivery
and the lying-in period.
In this latter sense prenatal care is as old as the human
race, but the terms prenatal care and especially the term pre
natal nurse are quite modern,
The study of the causes of infant mortality, to which your
society is devoted, has attracted public attention to the fact
that the greatest number of infants, who die under one year
of age, do not live to complete the first month of life, and that
the causes, leading to this enormous death rate, are often in
operation while the child is still within its mother's womb;
more often such early death is due to injuries which the child
has sustained at birth, or to lack of breast milk and proper
care during earliest infancy.
Attention having been called to this important factor among
the causes of infant mortality, it was natural that the proper
care of expectant mothers, including adequate provision for
confinement and the puerperal state, should have been sug-
gested as a preventive even by those, who were primarily inter-
174
HENRY SCHWARZ, M. D. 1T5
ested in the reduction of infant mortality alone. It was then
that the new terms were coined and that the prenatal nurse
made her appearance.
The experimental work, started by the Committee on Infant
Social Service of the Women's Municipal League of Boston
four years ago, has done more than any other undertaking in
America to call attention to the great possibilities for good
in such prenatal work, and to point out some of the obstacles
which will have to be removed before the benefits of compet-
ent prenatal care can be shared by expectant mothers in every
part of our country.
The work consists principally in placing pregnant women
as early as circumstances permit under the care of competent
visiting nurses, who devote their entire time to the work of
instructing these women in the hygiene of pregnancy, and who
see to it that these instructions are carried out.
The propaganda in favor of prenatal care, to which the re-
sults of this work have inspired the members of the Women's
Municipal League of Boston, has been and continues to be a
wonderful help to the various agencies which have been engaged
for some time in efforts to raise the standards of obstetrical
teaching and of obstetrical practice in America.
This is all the more gratifying when we consider that the
League has selected for its experiment a locality and a group
of expectant mothers, which are not at all suited to demon-
strate the full possibilities for preventing invalidism and for
reducing the death rate among mothers and babies contained
in adequate prenatal care.
The mothers experimented on were all women who had al-
ready placed themselves under the care of competent obstet-
ricians, which, after all, is or should be equivalent to secur-
ing all that most up-to-date prenatal care has to offer; these
women were all registered for delivery at the Boston Lying-
in Hospital or at the Massachusetts Homeopathic Hospital,
and they belonged to the enlightened class, who had expressed
the desire to be delivered in those institutions in preference to
their own homes.
When those of us, who are reasonably familiar with the
character of obstetrical work and of obstetrical teaching in
America, lament the fact that, in spite of the safeguards which
modern obstetrics provides for childbearing women, the great
majority of expectant mothers in this country do not benefit
by these provisions, we are not thinking of the poorer classes
in cities such as Boston, but we are thinking of the entire
population of every county in the United States.
176 PRENATAL CARE
In some of our cities, which are blessed by being the homes
of great medical and obstetrical centers, the poorest part of
the population and the wealthiest part of the population are
able to secure pretty good obstetrical care in the fullest sense
of the word; this portion of our population, therefore, fur-
nishes only a very small percentage of the thousands of women
and of the tens of thousands of infants, who die every year
in the United States in connection with childbearing from
causes, which in the majority of cases reasonable obstetrical
care would have prevented; nor does this fortunate portion
of the population of these fortunate cities furnish a consider-
able percentage of the incomparably larger number of mothers
and infants, whose health becomes permanently impaired from
these same preventable causes.
Let us state the case plainly : More than nine-tenths of all
expectant mothers in the United States receive no adequate
prenatal care; more than forty per cent of all confinements in
the United States are attended by male or female obstetricians,
who are not qualified to give to parturient women a full share
of the safety and comfort which modern obstetrics makes pos-
sible, and which ought to be the birthright of every expectant
mother and unborn child.
To be still plainer: Many thousand women die following
confinement, because they have been septically infected by
incompetent obstetrical attendants; other thousands die or
suffer impairment in health, because incompetent obstetrical
attendants have caused inexcusable injuries to the mother's
body during delivery, or have brought her to the brink of the
grave by improper management of the third stage of labor;
thousands of children die during delivery, because obstetrical
attendants are unable to make a correct obstetrical diagnosis,
and in consequence thereof crush out the life of the child
by brute force in ill-directed efforts at delivery, or, what is
worse, improper application of the forceps causes injuries to
the foetal skull, which result in mental deficiency or epilepsy,
and make many of these infants a charge on the community
and permanent inmates of public institutions.
Great numbers of infante are reported still-born, because
the obstetrical attendants are not skilled in the most efficient
methods for reviving infants born in asphyxiated condition;
the institutions for the blind are filled with people, whose eye-
sight has been lost during earliest infancy because the obstet-
rical attendants were neither skilled and conscientious enough
to prevent ophthalmia, nor were they skilled and conscientious
enough to cure the disease before it caused irreparable damage.
HENEY SCHWARZ, M. D. 177
This represents a fair estimate of obstetrical work in the
United States; excellent in places; good in a considerable
percentage, and absolutely bad in about forty per cent of the
entire work.
Before examining into the causes of this deplorable state
of affairs let us take comfort in the fact that these causes
are not specifically American; that the same or worse condi-
tions exist the world over, including such countries as Ger-
many and England, and that in the United States conditions
are improving more rapidly than in other countries.
There are three causes responsible for the poor care be-
stowed on expectant mothers. These three causes are: ignor-
ance and indifference of the laity concerning this entire mat-
ter; indifference and carelessness on the part of the states in the
supervision of medical schools and of schools of midwifery;
and neglect on the part of communities in not providing sys-
tematic care for all the sick poor, including expectant mothers.
This latter cause is specifically American.
Concerning the first cause, it may be said that it really
constitutes the only obstacle to bringing about the desired
reform; for just as soon as the women of America realize the
enormity of the crime which is being committed against the
expectant mother and her unborn child, they will force the
speedy removal of all the other causes by united and persistent
effort.
Tradition and ignorance are alike combined in spreading
the fable that child-bearing is a physiological process; that
since the existence of the world generations after generations
have been born and the race has multiplied in spite of the total
absence of modern obstetricians; that the Indians and other
peoples living in a state of nature get along mighty well with-
out special obstetrical care, and the story of the squaw, who
loiters behind a band of Indians, who delivers herself by the
roadside, mounts her pony and catches up with her friends, is
told time and again as a convincing proof against the neces-
sity of treating expectant mothers with particular care.
It is perfectly true that we can not improve on the workings
of nature; if we were to dispense with prenatal care entirely
and were to leave the women to deliver themselves as best they
can, the race would not suffer; in fact, it would be greatly im-
proved and it would go on multiplying; all those that are
handicapped would be eliminated, and, if we were to hasten
the process by treating all delicate or defective infants with
Spartan kindness, we would have a splendid object lesson of
the way in which nature works out problems in eugenics.
178 PRENATAL CARE
I have in my collection the uteri of two women of the Isle of
Guam, sent to me by a medical friend in the United States
Navy; both of these women died undelivered; they had been
unattended except by their own people; the one died of pla-
centa praevia, and the other on account of a face presentation.
Another tradition which ought to be stamped out is that
women have to suffer untold agonies in bearing children. It
is true that uterine contractions are necessary and wholesome,
and a certain amount of discomfort or even pain is unavoida-
ble. It is, likewise, true that the indiscriminate administra-
tion of anaesthetics during labor often causes relaxation and
hemorrhage after the child is born. On the other hand, with
a first child, no matter how easy may be the confinement,
there is almost always considerable suffering; the pain be-
comes excruciating at the moment when the head is born, and
there is almost always some injury to the maternal passages.
To give primiparous women enough chloroform or ether to
make them insensible to this severe final pain of the first con
finement, and to enable the obstetrician to repair the injured
parts before the woman recovers consciousness, is not only
permissable, but should constitute part of obstetrical routine.
To spread information regarding prenatal care, and thereby
to dispel the ignorance and indifference of the laity on this
subject, and to enlist its cooperation in efforts to bring about
State and Municipal legislation for the improvement of obstet-
rical conditions, must be the work of publicity campaigns and
of object lessons, such as are carried on by the Women's Muni-
cipal League of Boston ; the spread of such intelligence is rend-
ered more effective and begins to reach a great number of
women all over the country by the timely publications of the
Children's Bureau of the United States Department of Labor.
Eegarding the indifference and the neglect of the various
States of the Union in failing to provide efficient control over
medical schools and over schools of midwifery, and in failing
to subject candidates for license to practice obstetrics to rea-
sonable practical examinations, it may be said that, as far as
medical schools are concerned, most States are now beginning
to exercise such control, and that State Board Examiners are
getting more and more rigid in the examination of candidates
for license to practice medicine. The majority of these
boards require that candidates for examination be graduates
of medical schools in good standing; and very few boards
consider a school in good standing, which does not give prac-
tical bedside instruction in obstetrics. It is different with the
control of so-called schools of midwifery.
HENRY SCHWARZ, M. D. 179
The fact that a few States arrange for the examination and
registration of midwives, and that some States require that
candidates shall be graduates of duly incorporated schools of
midwifery, does not atone for the fact that some States espec-
ially exempt midwives from all provisions of medical practice
acts, and insist that they can practice without license and
control, nor does it atone for the fact that not one single State
in the Union has control over schools of midwifery in regard
to the character of instruction and the requirements for admis-
sion.
The cry is raised now and then to abolish the midwives en-
tirely; those who raise this cry forget that the obstetrical
service, rendered to a large portion of our population, will
not be improved by supplanting ignorant midwives by equally
ignorant doctors, especially when the ignorance of the doctor
is so much deadlier than that of the midwife. The doctor
comes in contact with a greater variety of infectious material,
and, by being more active in the application of instruments,
he can do much more harm than can an equally ignorant mid-
wife. Nor will it help the poorer population if we supplant
a five or ten dollar midwife with a fifteen or twenty-five dol-
lar doctor; the former, at least, acts as a cheap visiting nurse
and takes care of mother and baby for a few days, while the
latter requires the services of some other person for the work
usually done by the midwife.
A simple and efficient means to do away with midwives
without making martyrs of them and without working a hard-
ship on a certain part of the population, consists in getting
the same kind of State control over schools of midwifery and
the admission of midwives to practice as is exercised over
medical schools and the admission to medical practice.
Demand that these schools do a reasonable amount of bed-
side teaching, and that they train their pupils sufficiently
to enable them to give safe and intelligent obstetrical service.
This can only be done if certain entrance requirements are
insisted upon, and eventually nothing short of a four years'
high school education ought to be accepted.
This would, most likely, close these schools for lack of ap-
plicants; young women, with such preliminary education,
would much prefer to enter a training school for nurses and
engage in one of the many special fields to which the course
in a nurses' training school has become the stepping stone.
The present day midwife, of course, has no social standing,
nor is her earning capacity very great if she limits herself to
honest work. Therefore, getting control over schools of mid-
180 PRENATAL CARE
wifery and providing reasonable entrance requirements for
them, will very likely drive these schools out of existence.
Those midwives, who are now practising, will soon be driven
to less harmful employment. In the cities the development
of well organized obstetrical dispensary services with a sys-
tem of visiting nurses before and after delivery, is already
driving the midwife out step by step, and in the country the
same may be expected from the activities of rural nurses, who
are getting to be great factors for good in every remote corner
of our country.
It should be said right here, that the most effective agents
for spreading needful information among the people regarding
prenatal care and similar topics, are the graduates of our
nurses' training schools. Even at present a well-trained nurse
makes a much safer obstetrical attendant than the best mid-
wife, and, by giving some members of this intelligent class of
workers a little special instruction, they can be fitted to sup-
plant midwives in rural districts.
The midwife question in America is not as difficult to han-
dle as it is in some other parts of the world. In Germany,
for instance, the midwives continue to be of such low general
education that they can not be entrusted with the use of
the most potent antiseptics nor with the use of the hypodermic
syringe, nor with the administration of chloroform or ether,
and, since they are the only obstetrical attendants for the
largest portion of the population, the women entrusted to
their care must go on with the traditional suffering, and in
many instances they must go on without timely repair of
perineal lacerations, and all this, because the Government
can not impose reasonable entrance requirements without
changing the entire system of rural midwives (Gemeinde-
Hebammen). Each village is required to maintain a midwife,
who takes care of the village poor. For this work she receives
annually certain emoluments from the community; for serv-
ices rendered to villagers not on the poor list the midwife
receives a modest fee. Her training she has obtained in a gov-
ernment school for midwives at the expense of the village.
When it becomes necessary to have a successor trained for
such a village midwife, the mayor selects the most suitable one
from the village-bred applicants for the position; intelligence
and education are not always in evidence. At two German
universities, where village midwives receive their training, I
have for four years given the candidates a preliminary exam-
ination in reading and writing, and have several times sent a
candidate back to her village, usually with the result that she
HENRY SCHWARZ, M. D. 181
returned in a few days with a statement from the mayor that
she was the smartest woman in the village, or, at any rate,
among the applicants, and that we had better keep her; which,
of course, we did.
It is for such reasons that in Germany the entrance require-
ments for these schools must remain low, unless the govern-
ment changes the entire system and makes the village support
a well-trained midwife, who is not village-bred, just like most
villages are supplied with fairly efficient school teachers, who
are not village-bred.
We surely may hope to enlighten the laity on the benefits
of prenatal care, and we may, likewise, hope that in the
course of time the entire country will be supplied with fairly
well-trained obstetricians, but to make the blessings of ade-
quate care during pregnancy, parturition and the lying-in-
state accessible to all expectant mothers it will be necessary
to rouse large and small communities to a realization of their
solemn duty to provide such care for the poor at public ex-
pense, and to appreciate the immense benefit to the community
if it makes these blessings also accessible to those in moderate
means by contributing liberally from the public funds to the
upkeep of institutions, which take care of this class of cases
at a price which is proportionate to their means.
So far I have not entered into the nature of prenatal care
itself; it is not necessary to do so before this audience; but
I do wish to emphasize certain points regarding the care of
expectant mothers prior to confinement, and to show how that
work has been carried on for many years in the obstetrical
clinics of Washington University. The care of dispensary
patients should not differ from the care of private patients.
There is, however, this difference : of the six or seven hundred
obstetrical cases, who register annually at our dispensary
very few make application before the middle of pregnancy,
and therefore, do not receive the full benefit of prenatal care.
On the other hand, my private cases, with few exceptions, ap-
ply just as soon as their condition is known to themselves,
and I am, therefore, responsible for any accident that may
happen to them, if such accident could have been avoided by
reasonable prenatal care.
At the time of registering every pregnant woman should be
examined as to the position and size of her uterus and the con-
dition of surrounding structures, because now and then the
ovum is implanted in the tubes and not in the womb, and time-
ly detection of such ectopic gestation enables the obstetrician
182 PRENATAL CARE
to remove it before its rupture lias brought the patient into
imminent danger.
Such early examination, likewise, reveals existing malposi-
tions of the uterus; such cases at times need especial care
until the uterus has fairly risen into the abdomen.
Every pregnant woman is instructed in the hygiene of preg-
nancy as far as diet, exercise, work and dress are concerned.
She is particularly told to keep all organs of elimination in
perfect condition; that is to say, to keep the bowels open; to
keep the kidneys flushed by drinking plenty of pure water,
and to keep the pores of the skin open by frequent bathing
or washing. She is told to submit a specimen of urine once a
month up to the middle of pregnancy, and twice a month after
that period.
Her attention is drawn to the significance of certain symp-
toms, such as persistent headaches, disturbed vision, oedemat-
ous swellings, or escape of blood, and she is requested to re-
port at regular intervals at the dispensary. Towards the end
of pregnancy special attention is paid to the care of the nip-
ples, and the skin of the abdomen. The condition of the pelvis
is ascertained in every case by careful and repeated pelvic
measurements. The cases are assorted according to pelvic con-
ditions, and all those in which trouble may be expected are
requested to enter the hospital at such a time as may seem
best for delivering these particular cases.
All cases, no matter how normal conditions may seem, are
examined about a week before their expected time, and, if in
first pregnant women it is found that the presenting part has
not entered the pelvis, these cases are, likewise, requested to
enter the hospital.
That toxemia and eclampsia are in large measure preventa-
ble conditions, is fully affirmed by the results obtained in our
dispensary and in private practice; but even if pre-eclamptic
symptoms have developed, timely recognition usually prevents
the outbreak of convulsions, and, at any rate, it enables us to
meet the condition promptly and effectively.
Any one of these many advantages of prenatal care should
insure its general introduction; the neglect of a physician to
exercise reasonable care over expectant mothers, after they
have placed themselves in his hands, should before long con-
stitute an act of criminal negligence.
DISCUSSION
Dr. Philip Van Ingen, New York: I was particularly inter-
ested in the statement that was made in regard to the women
DISCUSSION 183
in the poor quarters of our city being turned over to male and
female obstetricians, putting midwives and a certain portion
of the medical profession working in such districts, in the same
class. That's what we must bear in mind when we consider the
midwife problem; that they are not much more poorly qualified
to take care of obstetrical cases than some of the doctors prac-
ticing in the poor parts of the city.
The statement that 90 per cent of our American women are
absolutely without prenatal care is of great importance. That
makes America almost the only country which does not provide
care for the expectant mother. When I was in London at the
recent Conference on Infant Mortality, it was the subject of
much discussion that the one part of our problem which has
received little or no attention is the expectant mother* In
this country everywhere we are beginning to organize campaigns
for the expectant mother. I don't know enough of what is
going on in other cities, except in a general way, to talk about
them. I can only tell you what we are doing in New York.
The New York Milk Committee has carried on for two years
an extensive campaign of prenatal instruction. We have had
2,003 mothers in our care. They are visited regularly every
ten days to two weeks from the time they are enrolled until
the baby is a month old. It makes no difference whether the
mother will be confined in the hospital, or by a physician or
midwife in her home. Our idea is to see what can be done
under existing conditions to improve the chance of that mother
and her baby. We have had 2,070 babies. Our stillbirth rate
during that time has amounted to 24 per thousand. That takes
in only babies born after the sixth month of gestation. Count-
ing all together it is 36 per thousand. Nearly 20 per cent of
our stillbirths have been during the third month of pregnancy.
Our rate of stillbirths among our supervised mothers has been
25 per cent lower than for the Borough of Manhattan during
the same period. Of babies who were born alive, there have
been 25 per cent less deaths during the first month than for
the same period in the Borough as a whole. Of our mothers,
93 per cent of all those whose babies were living at the end of
the first month were nursing them entirely. Only three and a
fraction per cent were being fed artificially. The American-
born mother stands next to the Italian in her ability to nurse
her baby, as judged by the figures at the end of the first month.
The Italian mother is 93.40 per cent, and the American mother
is 93.07 per cent.
We realize that what we are doing is open to criticism. We
do the best we can to secure our mothers the best eare they
184 PEENATAL CARE
can get. If it is best we urge them to go to the hospital. In
the districts where we are working we don't feel, from what
we have seen and really we have approached the matter with
open minds we don't feel that we are urging the mother to
do anything very much better when we suggest that she sub-
stitute local medical attention for the midwife's attention.
The Bellevue School of Midwives does a great deal for these
mothers. The care that they get and the supervision that is
exercised over the midwives is good. I am not one of those
who believe that the midwife is a desirable institution. But I
do believe that for many years to come the midwife is a neces-
sity. I believe that the trained midwife, the one who is taught
how to take care of her women, the midwife who is regulated
by the authorities and not allowed to interfere, I might say,
the female obstetrician, is less dangerous than the male obste-
trician in our poor quarters.
The Chairman: We are fortunate is now having a Children's
Bureau in the Federal Government. The fact that one of the
first publications issued by the Bureau is on Prenatal Care, is
significant of the importance attached to the subject, and is a
matter of gratification to this Committee. We are fortunate
in having Mrs. Max West, of the Children's Bure&u, with us.
Mrs. Max West, Washington, D. C.: Dr. Schwarz, in his
extremely suggestive and comprehensive statement of the sub-
ject under discussion, has mentioned certain factors which are
working to bring about a betterment of the conditions which
he has so graphically described. I have the honor to represent
here today the youngest and the least tried of these factors,
the Children's Bureau, which is endeavoring to carry forward
its work in behalf of the health and welfare of the children of
this country by striving to show mothers how to take care of
themselves before the babies are born.
The reasons for undertaking this work were not far to seek.
The latest report on Mortality Statistics by the Bureau of the
Census shows that about 63,000 babies, or enough to make up
the entire population of Fort Wayne, for example, died in the
Kegistration Area of the United States in 1911, before they had
lived to be one month of age, and that of this number more
than 69 per cent or enough babies to provide the total popula-
tion of a city as large as Topeka or Lincoln, died of specifically
prenatal causes or injuries or accidents at birth (43,546).
These figures, shocking as they are to all thoughtful persons, do
not, unhappily, tell the whole story, since only 63 per cent of
the population of the United States is included in the Regis-
DISCUSSION 185
tration Area at present, and it is a perfectly safe assumption
that the proportion of infant deaths is not less in the non-
registration area. The causes of death, covered by the figures
you have heard are congenital debility, malformations, prema-
ture births, and accidents or injuries at birth. If to these are
added the numbers of those who died from certain other
assigned causes, which manifestly must have been to some
extent operative before birth, such as the various forms of
tuberculosis, syphilis and organic diseases of the heart, for
example, and if, finally, is added the number of stillbirths,
which unfortunately rests on nothing better than estimates in
the present state of statistical development in this country,
but which is believed by experts to be not less than 100,000 for
the whole United States, we should have approximately 150,000
deaths of infants under one month traceable to conditions
existing before birth took place, and this does not take account
of the enormous but unknown number of induced and other
miscarriages. What number or proportion of such deaths can
be prevented by adequate prenatal care is, of course, impossible
to determine, but the experiences of those who are engaged in
this work go to show that a very large proportion of these
deaths were wholly needless, and could have been prevented by
the application of known rules of healthful living. In this
conviction the Children's Bureau entered upon the preparation
of a set of instructions for the use of women awaiting mother-
hood, and on the 16th of last August the pamphlet entitled
Prenatal Care appeared. The method followed in its prepara-
tion was, first, to read and study the literature of the subject,
or such part of it as was available; second, to observe and
learn from the practical experience of those who were carrying
on such work, as for example, the New York Association for
Improving the Condition of the Poor, the New York Milk Com-
mittee, and the Women's Municipal League in Boston, through
its Committee on Infant Social Service, all of whom put every
facility for seeing their work at the disposal of the Bureau;
and third, by seeking the counsel and advice of specialists in
obstetrics. This help was always most cordially given. The
members of the medical profession have been generous and
unfailing in their cordial assistance, and, without exception,
they have accepted our pamphlet as evidence of the earnest
desire of the Bureau to cooperate with them at all times, by
making the results of their study and experience available to
women everywhere.
The pamphlet has been available for free distribution npon
request for 12 weeks. The first edition of 7,500 was taken up
186 PRENATAL CARE
within three weeks, and up to the present time we have dis-
tributed 20,000 copies, with requests coming in steadily at the
rate of approximately 100 per day. The distribution has been
guarded with rather unusual care to insure that the pamphlet
should reach only those who would make use of it. By far the
greater part of the requests have come directly from interested
women, from physicians, from nurses and from heads of various
organizations .and institutions, municipal, social, philanthropic
and educational, all of whom are in a position to make a very
direct application of the document. The eugenists present will
perhaps be interested to hear that a few ministers have asked
to have copies of the pamphlet to include one with each cer-
tificate of marriage, and that not a few similar requests have
come from secretaries of Young Men's Christian Associations
in all parts of the country, and Campfire Girls. One of the
most encouraging features of the work we 'are here interested
in, it seems to me, is the avidity with which the women are
seizing upon this means of education and instruction. The
correspondence of the Bureau affords abundant, often pathetic,
evidence of the eagerness of all women to inform themselves
upon these vital matters, coming, as the letters do, not only
from every part of the United States, but from Cuba, Porto
Kieo, the Philippines, Canada and many foreign countries,
but also, and much more significantly, from women of every
class of wealth, social standing and education, all alike, eager
for the help they hope thus to get.
The pamphlet on Prenatal Care, which is the first in our Care
of Children Series, attempts to set forth as simply as possible
the hygienic rules of pregnancy, and includes a brief chapter on
the Nursing Mother. It endeavors, first of all, to be reassuring,
showing that motherhood is a perfectly normal experience, and
that suitable and sufficient prenatal care involves no mysteri-
ous knowledge hitherto hidden from the eyes of women, but
consists chiefly in the resolute application of the plain rules
of health. It urges that symptoms of illness should be brought
at once to the attention of a physician, pointing out that such
attention is of much greater service in preventing serious
trouble later than it could be after the fact. In general, it
strives to avoid controversial points and to convey well-authen-
ticated information in the most direct way.
They tell a story over at the Department of Agriculture of
the Horse Book, as the publication is familiarly known. This
book has been printed and reprinted in enormous editions until
somewhere in the neighborhood, it is said, of la million copies
of the book have been distributed free of charge to interested
DISCUSSION 187
horse-owners throughout the country., probably the largest dis-
tribution ever given to any one government publication. The
bulletin deals with the subject of the diseases of the horse.
Let us not presume to belittle the importance of this subject !
Since the automobile has shorn him of so much of his popu-
larity let us give every attention to his diseases, but in passing
I merely beg to call attention to the fact that there is another
Government publication which deals with the subject of the
health of human mothers and babies, to be had with the same
ease, and equally free of charge I
Mrs. Wm. Lowell Putnam, Boston: The Committee on Infant
Social Serice of The Women's Municipal League of Boston has
been devoting the greater part of its time during the past year
to giving prenatal care, although it has also been trying for the
past eighteen months to introduce teaching in the care of
babies into the regular curriculum of the grammar school, for
girls of the seventh and eighth grades. Some progress has
been made in this matter.
In prenatal work the Committee continues to employ but one
nurse, as its object is not personally to carry on prenatal care
on a large scale, but simply to try experiments with a view to
helping other agencies to put its results into larger practice.
The number of patients cared for is thus smaller than in pre-
vious years, because, for the first time, throughout the full
year, half of the nurse's time has been given to build-
ing up and supervising the prenatal work of the Instructive
District Nursing Association of Boston. This has been made
possible because the Boston Lying-in Hospital, whose house
patients were taken care of by this Committee, having become
convinced of the importance of prenatal care, has now for
nearly two years employed a nurse for this purpose.
The result of the year's work has been very satisfactory and
shows on the whole a steady decrease in threatened eclampsia,
in premature births and in stillbirths, although the exact
figures are liable to slight fluctuations.
In the last annual report of this Committee to the Women's
Municipal League of Boston (which report is made up on April
15) the following comparative statistics are given:
188 PRENATAL CARE
COMPARATIVE STATISTICS.
April 15, #09 April 15, 191S
Percentage of cases of threatened eclampsia to total number
of patients :
1st year 10.2%
2nd year 4.8%
3rd year 1.7%
4th year
Percentage of stillbirths to total number of babies :
Average for three years 2.6%
26 per thousand births
Average for fourth year 1.7%
17 per thousand births
Percentage of premature births to total number of babies :
Average for three years 1.7%
Average for fourth year 7%
Average birth weight for whole period 7 Ibs. 9^ oz.
Average birth weight for fourth year alone. 7 Ibs. 12 oz.
Miscarriages :
1st year 2
2nd year 1
3rd year
4th year
In the statistics for the present annual report ending Octo-
ber 15th ? there appears a slight variation from those given above.
The percentage of threatened eclampsia this year has been
.9 per cent, a slight increase over the previous report. The still-
births also have been slightly higher, 18 per thousand births, as
against 17 per thousand last year. It is of interest to compare
this rate with that of the city at large, as shown in the statis-
tics given by Dr. William H. Davis at the meeting of this
Association in 1912. He gives the stillbirths in Boston for
the last twenty years as varying between 33.1 and 44.7 per
thousand living births whereas as just stated, the rate
of this Committee for the past two years has not exceeded
18.6 per thousand. This rate, including as it does,
accidents during labor, is a striking illustration of the value
of prenatal care. According to the statistics of the City of
Boston, the number of births in the city in 1912 was approxi-
mately 19,000, and the percentage of stillbirths in that year
was 39.3 per thousand living births. Had our percentage of
stillbirths pertained throughout the whole city 393 babies
would have been born alive whose lives, as it was, were extin-
guished before they saw the light of day.
DISCUSSION
The premature births have been reduced so that they stand
this year at A per cent. The prevention of the birth of children
before their time must result in better health and greater
vigor and in saving of much needless suffering and expense.
One case of eclampsia has developed this year in spite of the
care; a post-partum case in which no premonitory symptoms
whatever could be detected.
The Committee has now carried to confinement 1,492 cases,
besides caring for many others through varying periods, and
it still believes that the limit of time allowed between visits
should never exceed ten days, and that weekly visits are to be
preferred, with a test of the blood pressure and the urine made
at every visit.
For the first time the Committee has throughout the whole
year made a special investigation of the method of feeding and
condition of the child at the end of the first month, as this
seems one of the best indications of the value of prenatal
care. The statistics are as follows :
METHOD OF FEEDING DETERMINED AT END OF FIRST MONTH.
Breast fed 86.3<%
Bottle fed 10.7%
Mixed feeding 2,8%
CONDITION OF BABIES AT END OF FIRST MONTH.
Method of Feeding
Known
Breast fed Bottle fed Mixed feeding Unknoion
Well 97.85% Well 71.5% Well 100% Well
111 2.15% 111 28.5% IU 111
Dead Dead Dead Dead 3.6%
These statistics are of peculiar value in showing unquali-
fiedly the benefit of prenatal care, as the Committee gives up
all care of mother or child at the onset of labor.
The exhibit of the Committee was shown in Washington at
the XV International Congress on Hygiene and Demography
and has since been traveling throughout the State of Massa-
chusetts, together with that of the State Board of Health and
other Massachusetts organizations.
The spread of this work through other agencies in this city
to other cities of the United States and even to foreign
countries, has been most encouraging.
The Boston Lying-in Hospital, as already stated, began this
work about two years ago, as did also the Boston Board of
Health.
190 PRENATAL CARE
In 1911 and 1912 New Yiork, Milwaukee, St. Louis, Balti-
more, Chicago, Buffalo, Fall Eiver and other cities instituted
care along the lines of the work of this Committee. The
statistics compiled a short time ago by the Federal Children's
Bureau emphasize the value of the work, and they show that 42
per cent of the mortality of the first year of life occurs during
the first month. Within the past week a request has come to
the Committee from the University of California for schedule
cards and general information to help in carrying on the work
there. Dr. Slemons writes that one of his first requests was
for a prenatal nurse. In his letter he says : "The value of such
work has been clearly demonstrated in the four weeks the
nurse has been working. She has brought to our knowledge
several cases of albuminuria that otherwise would have escaped
detection until convulsions occurred."
From Edinburgh Dr. Ballantyne writes, speaking of an
article in the British Medical Journal: "You will notice on
page 825 of the number for September 27th, a reference to your
prenatal nurse at Boston; you will also notice that I have
adopted the idea in a form in our Maternity Hospital here.
We have had the internal arrangements for pregnancy cases
for twelve years, and the out-door development begins now."
The knowledge of the importance of prenatal care is rolling
up like a snowball, thanks to the enthusiasm of the members of
this Association ; and the further it rolls the more it enlarges
its borders.*
* Since writing this report, a letter has been received from the Health Officer
of Melbourne, Australia, asking for detailed information about the work, and
saying "one cannot "but be seized by its great importance."
THE IDEAL OBSTETRIC OUT-PATIENT CUNIC
P. S. NEWELL, M. D., Boston
In considering the subject which has been assigned to me
for discussion, "The Ideal Obstetric Out-Patient Clinic/ 3 I
have tried to formulate a general scheme which, with modi-
fications to suit local conditions, can be fitted to the needs
of any community. It is impossible, in my opinion, to elab-
orate a plan which is suited to all communities in minor
details, owing to the varying conditions existent in the differ-
ent communities, and, therefore, all that I have tried to do
is to formulate a general outline which is susceptible of
modification according to the needs of the community in which
the out-patient clinic is to be established.
For an out-patient obstetric clinic to be of value to and
therefore successful in any community it is necessary that
there be a recognized need in the community for such a clinic.
In other words, there must be a considerable population in
that community whose circumstances are such that they re-
quire free or practically free medical attendance, and who
receive inadequate care from the physicians who practise
among them, a condition that exists in practically all of our
large centers of population where the immigrant population
tends to congregate. The number of these patients must be
so considerable that the experience gained from their care
will compensate for the time and money spent on them, as
otherwise the care that they will receive will be perfunctory
and they will be little, if any, better off than if no opportunity
for dispensary care were afforded them, and one of the prin-
cipal objects of such a clinic is to provide as good care for the
poor as the well-to-do can command.
The second element necessary to the foundation of such a
clinic is a constant supply of medical students or young physi-
cians to whom the valuable experience gained from the care
of these patients is sufficient compensation and who are able
to devote themselves entirely to the work of the clinic when
they are assigned to duty.
These two factors render it necessary that the ideal out-
patient clinic should be founded in a city of at least moderate
size in which there exists a considerable laboring class, and
191
192 THE IDEAL OBSTETRIC OUT-PATIENT CLINIC
preferably a city in which a medical school exists from which
students can be drawn to care for the patients under the
auspices of the clinic, or failing a medical school, a consider-
able number of young physicians who are both willing and
able to undertake the care of the unpaid obstetric cases on
the same basis that they would accept a well-to-do patient in
order to gain the experience which can only be obtained from
the care of a large number of patients. In charge of the
clinic must be one or more well-trained obstetricians, who
shall oversee the work and who are qualified to assume the
care of the major abnormalities, which are sure to arise
among any considerable number of patients; and who have
access to a surgically equipped hospital in which the more
serious obstetrical complications can be adequately treated.
These then are the essentials for the ideal clinic, a large
number of patients, a sufficient number of medical students
or young physicians to carry on the routine work under the
oversight of one or more well-trained obstetricians, and a well-
equipped hospital in which the more serious cases can receive
adequate care.
Abnormal obstetric cases are apt to receive relatively poor
care at home, even among the well-to-do, and for the poor
patient the hospital is an economic necessity if good results
are to be obtained. In addition a corps of trained nurses to
visit the patients in their homes, both during the pregnancy
and after delivery, while not absolutely essential for the well-
being of the patient, will markedly increase the efficiency of
the clinic and raise the standard of the work done, since they
will perform many duties which would otherwise divert the
medical attendant from the medical care of the case, and fur-
ther act as a strong educational factor in teaching the pati-
ents first the importance of proper hygiene both during preg-
nancy and after delivery, and second how to approximate this
ideal to the means which are at their command. In order to
obtain the best results and to be of the greatest benefit to the
community the obstetric clinic must aim first at giving its
patients such care as will lead that portion of the population
which has been in the habit of depending on midwives or on
poorly equipped physicians to place themselves in the care of
the clinic, and in the second place to educate the community
by showing results as to the importance of the proper care
of pregnancy and labor, and thus raise the standard of obstet-
ric practice in the whole community.
One of the difficulties in out-patient work arises from the
fact that the patients who belong to the class in the com
F. S. NEWELL, M. D. 193
munity for whom the out-patient clinic is established have
never been educated to the importance of a proper super-
vision of pregnancy, and every lying-in hospital is handicapped
in its work by the fact that most of the serious cases which it is
called on to treat have had no care during pregnancy and the
complications which have arisen are seen late, often at a time
when a bad result is inevitable, whereas if the patient had
been under supervision early in pregnancy the complication
would have been recognized early and the patient given such
attention and advice as to at least favor, if not insure, a good
result. It is perfectly natural that the lowest class in the
community from whom most of the patients must be drawn
should not recognize the importance of care during pregnancy
when we see how few patients of the well-educated class really
understand the importance of proper care during pregnancy
and how comparatively few physicians have had sufficient
obstetric training to appreciate the needs of their patients for
unusual care before complications become serious. The
trained obstetrician recognizes that the majority of the bad
results could be avoided, if the patients were under intelligent
supervision throughout pregnancy, and for an out-patient
clinic to be properly conducted such a provision must be made.
The work of the out-patient clinic can best be considered
under three headings : first, the care of pregnancy ; second, the
care of labor, and, third, after-care.
THE CARE OF PREGNANCY
In order to give the patients proper care during pregnancy
a clinic for the care and study of pregnancy must be estab-
lished under the charge, preferably of a lying-in hospital, in
which all patients who apply to the clinic for treatment shall
be studied, and one of the requirements which should be in-
sisted on if a patient is to be cared for by the clinic is that
every patient should report at the clinic at regular intervals,
even though she may be perfectly well. In charge of this
pre-natal clinic should be one or more physicians who have had
a good obstetric training and who are, therefore, in a position to
recognize any obstetric abnormalities which may be present in a
given case, and to make provision for whatever special care the
patient requires either at her home or in the hospital accord-
ing to the nature of the case.
At her first visit to the pre-natal clinic each patient should
be thoroughly examined and any abnormality noted, and her
previous obstetric history, if any, should be taken. She
194 THE IDEAL OBSTETRIC OUT-PATIENT CLINIC
should then be given such simple instructions in regard to
the hygiene of pregnancy as her intelligence and conditions
of life will allow her to carry out. We cannot expect the
woman of the laboring class to be able to regulate her life
as accurately as her more fortunate sister, but the essentials
of the hygiene of pregnancy can be followed by any patient,
and will be followed by the great majority if the instructions
that she receives are clear and simple, and the reason for the
care made clear to her. At the first visit the patient should
be instructed to report at the clinic at certain stated inter-
vals and to bring a specimen of urine with her for examina-
tion at each visit, and a careful record should be kept of the
time when each patient is to report.
During the intervals between these visits the patient should
be visited at her home by a trained nurse who can modify the
directions for hygiene given at the clinic to suit the conditions
of the home, in regard to which the doctor is often ignorant,
impress on the patient still further the importance of carry-
ing out these directions, take the blood pressure, etc., and
remind her that she is expected at the clinic at a certain
date. If the patient does not report at the clinic as directed
she should then be visited again by the nurse, or better, by one
of the physicians on duty in the clinic to ascertain whether
she has any good and sufficient reason for not reporting at the
clinic, and she should then be informed that unless she reports
to the clinic as directed she must look elsewhere for care and
that the clinic will only assume responsibility for her if she
obeys directions and under no other conditions. If possible
it might be well, although it is not essential, for each patient
to be visited at home in the intervals between her visits at
the clinic by one of the physicians attached to the clinic to
supplement the observations of the trained nurse and to make
sure that everything is as it should be. The results of the
nurse's visit should be reported to the clinic and filed with the
patient's record for future use.
A month or six weeks before delivery the patient should be
thoroughly examined. The pelvis should be again measured
and the relation between the size of the child and the pelvis
accurately determined, and from this time on the patient
should be seen either at the clinic or at her home by the
nurse at least every ten days. Such a supervision of preg-
nancy must result in the discovery of many abnormalities
early in their course and insure to the patient proper care
at the time of delivery, and each patient should in addition
be instructed to report promptly any abnormal symptoms
P. S. NEWELL, M. D. 195
which may arise between the visits of the nurse. The patient
should be tabulated in the records of the clinic as being nor-
mal, doubtful, or abnormal, and such provision made as seems
best to transmit such information to the department of the
out-patient clinic in charge of the labor, in such form, that,
when the patient sends to the clinic for a doctor to care for
the labor, a glance at her record will show whether she needs
any special attention at the time of labor.
No definitely abnormal patient should be cared for in her
home, and all patients who are found to present a definite
abnormality, whether it consist of pelvic disproportion, tox-
emia of pregnancy, or merely a history of obstetric disasters
in the past, should be cared for in the hospital, for the tene-
ment house furnishes no adequate means for caring for ob-
stetric abnormalities, whether operative or due to disease.
Only such patients should be placed in the doubtful class
as those in whom no definite abnormality can be discovered,
even after examination under anesthesia. Such cases, for
example, are primiparae, in whom at the end of pregnancy
the fetal head remains high, but in whom a careful examina-
tion has failed to show any disproportion between the child
and the pelvic canal or other recognizable abnormality, and in
whom it is felt that the onset of labor will be attended by a
prompt descent of the head into the pelvis.
In my opinion, the ideal obstetric out-patient clinic should
deal entirely with normal cases or those requiring simple oper-
ative procedures, and never attempt to care for serious cases
except in emergencies, such as prolapse of the cord, in which
immediate operation is necessary for the sake of the child
and the time lost in moving the patient to the hospital might
be a serious factor in the result.
If students are employed to perform the routine work they
should be assigned to duty in the pre-natal clinic where they
would gain a very valuable experience in the care of preg-
nancy, a subject which at the present time is seldom provided
for in our medical schools, with the result that while the
majority of men enter practice with a considerable knowledge
of the methods of normal or operative labor, they have little
or no experience in the care of pregnancy and the early recog-
nition of possible abnormalities and do not realize its im-
portance, a fact which accounts for the condition which we see
in general practice that treatment of abnormalities and not
prophylaxis is given the greatest attention, and that the care
of pregnancy is largely neglected.
196 THE IDEAL OBSTETRIC OUT-PATIENT CLINIC
CARE OP LABOR
The care of labor should be assigned to another department
of the out-patient clinic, but the relation between the two
departments should be such that all the records of the pre-
natal department should be immediately accessible, so that
when a patient sends to the out-patient clinic for a doctor
at the time of labor he shall go to the case with the full
knowledge of the previous history of the patient just as does
a physician in private practice, or at least he should know
whether the patient is classed as normal or as a doubtful
risk.
Under ideal conditions the actual care during labor and at
the time of delivery should be under the charge of third or
fourth year medical students, or failing these, of young grad-
uates to whom the experience gained in the conduct of a large
number of normal cases will prove of value. During their
term of service at the clinic they should have no outside
duties or calls and should remain ready to answer calls day
and night. In a clinic of any size this work is very exacting
and the term of service should be comparatively short, not over
two weeks, in my opinion, at any time, owing to the physical
exhaustion which the work entails. The number of men as-
signed to the clinic at a given time must be regulated by two
factors, first the number of patients under the charge of the
clinic, and second the number of students who are obtainable
to do the work.
In our own clinic where we care for some two thousand
patients a year, with a fairly wide geographical distribution,
we maintain two stations in different portions of the city and
try to have four students on duty at each station under direct
charge of an out-patient house officer who is a graduate of a
general hospital before he comes to the lying-in hospital. One
student goes off duty each Wednesday and Saturday, and his
place is filled by a fresh man, so that in times of stress there
are always one or two men who are physically able to bear
the burden and allow the men who have been on duty longer
a chance for sleep, which is often needed. ,
When the patient applies to the hospital for care, her record
should be inspected and a student assigned to the case. He
should preferably make his first visit alone, since, in my opin-
ion, if the student is accompanied by a house officer or by a
member of the out-patient staff the patient is apt to lose con-
fidence in him, and even the presence of a trained nurse will
tend to lessen the student's reliance on himself, and, there-
F. S, NEWELL, M, D. 191
fore, tend to make him less efficient. Each student on leaving
the station should register the time and place of his call, and
if after a reasonable interval, say three or four hours, he has
not reported the conditions present, the house officer should
then make a personal call and check up the findings of the
student, give him such instructions as are necessary and direct
him to report the progress of the case at a given time or the
appearance of any abnormal symptoms as soon as discovered.
Each student should be required to watch several deliveries
in the hospital, if possible, before being assigned to duty, in
order that he may have a standard set which he will try to at-
tain in regard to the proper conduct of delivery. If no oppor-
tunity can be afforded in the hospital for such instruction it
should be obligatory for each student to attend several cases,
the more the better, as assistant to the student already on
duty.
We also find it a great advantage to maintain an instructor
attached to our clinic who endeavors to see each student with
one or more of his early cases and instruct him in the proper
methods to follow in attending a case, but our endeavor is
to give every student as much responsibility as is possible
without detriment to the patient, in order to make him self-
reliant and increase his efficiency, feeling that by the proper
oversight before mentioned, we can safeguard the interests of
the patient fully and yet give the student a chance to gain
valuable experience on his own responsibility.
If every patient has been conscientiously supervised during
her pregnancy and if adequate provision is made so that no
case of prolonged labor can exist without being seen by a
competent obstetrician the actual work of delivery can be
left safely to the student under supervision without fear that
the patient's interest will be jeopardized and the work of the
out-patient clinic will be reduced, as it properly should be,
to the care of normal labor or low forceps operations and the
study of the convalescence of the patient. Of course, an oc-
casional emergency may arise, such as prolapse of the cord
or premature separation of the placenta, which will call for
an operation of greater magnitude than is ordinarily contem-
plated in the patient's home, but these emergencies will be
few, and the objects of the clinic, to afford adequate care for
the parturient woman, and valuable experience for the stu-
dent in charge of the case, will be gained at a minimum of
risk, since, as far as possible, all abnormal cases will be re-
moved from the clinic and cared for in the hospital. Even
though carefully supervised the students should be required
198 THE IDEAL OBSTETRIC OUT-PATIENT CLINIC
to report progress on all patients who have been in labor
more than four hours; all patients who have been in the
second stage for two hours or over, whether making progress
or not; all cases of ante-partum or post-partum bleeding and
all perineal lacerations, and provision should be made at the
out-patient station so that any call which the students may
send in can be answered promptly by the physician or house
officer in charge of the work. Care should be taken to see that
too great responsibility is not placed on the house officer, and
a competent obstetrician should always be in charge of the
clinic who shall act as a consultant and assume charge of any
serious. cases which may arise at any time.
AFTER-CARE
The delivery having taken place and the patient being in
good condition at the end of delivery, the care of the con-
valescence becomes the next object to be considered. Each
student should be required to visit each patient whom he has
delivered at least twice a day for the first three days, taking
the patient's pulse and temperature, noting the character and
amount of the lochial discharge, examining the baby's eyes
and noting the establishment of lactation, etc. He should be
required to register the results of each visit at the out-patient
station so that his records may be examined at any time by
the house officer or physician in charge. The patient should
also receive daily visits from the trained nurse attached to
the clinic, at least for the first five days, unless the patient's
circumstances are such that she can provide a competent
nurse for herself, and the nurse should report immediately
any abnormality which may have escaped the student's atten-
tion, and instruct the patient as far as possible in the care
of herself and baby.
After the third day the student should visit the patient at
least once a day for the next four days and at such intervals
as may be necessary following that till the patient is dis-
charged from the care of the clinic.
The house officer or physician in charge of the clinic should
visit each patient on the third or fourth day after delivery
for the purpose of checking up the student's work and seeing
that his reports of the case are accurate, and no patient should
be discharged from the clinic till a complete examination has
been made by the house officer, which should include a vaginal
examination to ascertain the position of the uterus and the
progress of involution, the condition of the cervix and healing
F. S. NEWELL, M. D. 199
of any perineal tears which may have occurred. The condition
of the patient's breasts and the eyes and umbilicus of the
infant should be investigated, and no patient should be dis-
charged from the clinic who cannot be certified as obstetrically
well, unless she is transferred to the hospital for further care
or is discharged against advice owing to unwillingness to fol-
low out the directions which had been given her.
If any abnormality is found at the final examination nec-
essitating a subsequent operation the patient should be refer-
red to an appropriate hospital. In other words, for the work
of an out-patient clinic to be properly done the pregnancy and
labor and the convalescence of each individual patient should
be followed as carefully as the most conscientious obstetrician
would follow a patient in his private practice.
We all recognize that the care which the rank and file of
patients get during pregnancy, labor and convalescence, even
in fairly good practice is utterly inadequate to assure good
results, and the aim of every out-patient clinic should be to
give each patient as good care as she can receive from the
most conscientious obstetrician and to impress on the mind^
of the students the importance of such care in the hope that
the out-patient clinic will prove to be not only a blessing to
the patient, but a means of raising obstetrical practice from
the low plane on which it is conducted by the average prac-
titioner.
In good practice it is surprising how ignorant the average
mother is in regard to the care and feeding of her infant, and
in hospital practice this ignorance is naturally more marked.
Furthermore, the means of the working woman are often in-
adequate to provide proper food for her baby if she is unable
to nurse it satisfactorily. A close association between the ob-
stetric clinic and a pediatric clinic should therefore prove of
great value, and the ideal out-patient obstetric clinic demands
the establishment of an associated pediatric clinic to which
every patient discharged can be referred, the mother being in-
structed in the proper care of her infant and proper food pro-
vided in case she is unable to nurse. Probably in no way can
the mortality among infants be more reduced than by these
two clinics working in harmony, the obstetric clinic providing
for the care of the mother and child during pregnancy and
labor, while the pediatric clinic provides for the care of the
child at the time when such care is most valuable and teaches
the mother how to carry on the work afterwards.
The objection may be raised that the expense entailed in
the conduct of such an obstetric clinic is prohibitive, but our
200 THE IDEAL OBSTETRIC OUT-PATIENT CLINIC
experience has been that the voluntary contributions of the
patients who are grateful for the care they have received more
than pays the running expenses of the clinic, although in the
early years a deficit must be expected. The success of such
a clinic depends on being able to prove to the patients that
they will receive better care in the clinic than at the hands
of midwives or of poorly equipped practitioners. If this is
once demonstrated to the patients the growth of the clinic is
assured.
DISCUSSION
Dr. J, Whitridge Williams, Baltimore: I endorse almost
everything that Dr. Newell has said concerning the organiza-
tion of an ideal out-patient obstetrical clinic, but I shall not
occupy your time by discussing the minor points of difference
between us, as it would be neither profitable nor interesting
to this audience to go into details concerning the organization
and management of such a service.
Dr. NewelPs description applies almost entirely to his own
service in connection with the Boston Lying-in Hospital and
the Harvard Medical School, and to the opportunities it offers
to a certain proportion of the poor women of Boston. I am
inclined to believe that the discussion should cover a broader
field and should include the consideration of the following
points :
a. The best method of affording suitable obstetrical care to
all poor women who need it.
b. Its effect upon the community.
c. Its bearing upon the education of medical students.
d. Its influence in advancing knowledge.
Dr. NewelFs service and my own at the Johns Hopkins
Hospital in Baltimore, as well as others in various localities,
are doing excellent work, but unfortunately, it is relatively
limited; as must be the case when the charity is supported
by a university or hospital and is conducted primarily for
the instruction of students.
What we need is an extension of such services, so that they
may be available for all poor women living in our large cities,
and what we have to discuss is how it can be brought about.
I am particularly interested in the subject, as I have been
requested by the Board of Supervisors of City Charities of
Baltimore to devise a plan by which such a result can be
realized in that city.
DISCUSSION 201
Each of the three medical schools of Baltimore maintains a
larger or smaller out-patient obstetrical service whose work is
necessarily limited to the portion of the city in its immediate
vicinity and is hampered by lack of funds. Even if the money
necessary for their proper maintenance were available it
would not be feasible for the three services to attempt to
cover the entire city, as they are too remote from its outlying
parts, and if sub-stations were established and properly
manned, great difficulty would be encountered in giving them
the necessary supervision.
I believe that city-wide out-patient obstetrical care can be
secured only by co-operation with the State and Municipal
authorities, when the entire system could be co-ordinated and
conducted harmoniously and efficiently. Under such a plan
suitable subventions should be given to the poorer medical
schools in order to make possible the employment of a social
service worker and a prenatal nurse. The necessary number
of nurses to care for the patients at the time of labor and
afterwards should be provided by the school, while the medical
care would be given by trained assistants and students under
the supervision of the professor of obstetrics. Each school
should be expected to care for all women who might apply
from a specified territory, and any overlapping should be
carefully avoided. In the portions of the city far distant from
the schools, substations should be established and maintained
by the city. Each of these should be in charge of a competent
resident physician, who should have under him the necessary
numbers of nurses and workers, together with a number of
students from the several schools. Furthermore, each station
should have a connection with a specified hospital, to which
all abnormal cases should be sent; while the entire organiza-
tion, including the medical school services, should be super-
vised by a broad-minded medical director and a competent
social service worker. The services of such a department
should be available for all women whose husbands have a
maximum income of f 600 or $700, and should be free to the
very poor, while a small fee should be charged those who are
somewhat better off.
Of course, it might be objected that such a scheme would
involve the city in too great expense, and that it would be
impossible to induce the politicians to appropriate the neces-
sary funds for its support. To my mind, neither of these
objections would hold ; as I believe if those who could afford
to do so, paid the service the usual midwife fees, that it would
not cost over $12,000 to $15,000 a year in a city of one-half
202 THE IDEAL OBSTETRIC OUT-PATIENT CLINIC
million inhabitants. Furthermore, I am confident that the
politicians could be interested in the scheme; as I know from
my own experience that even politicians of the type which
brings despair to the reformers will lend a ready ear and a
helping hand to any proposition which offers a reasonable
prospect of materially improving the condition of the poor.
This brings us to our second point the effect of such a
plan upon the community. In the first place, it would save
many women from invalidism and operation, as it is well
known that more than one-half of all gynecological operations
are rendered necessary by conditions resulting from infection
or the faulty treatment of labor or abortion. Many of these
complications would be prevented but when they occurred
proper treatment would frequently bring about prompt recov-
ery, so that the city would be spared at least part of the
expense now incurred for the maintenance of gynecological
beds in hospitals. Furthermore, intelligent prenatal care
would prevent many of the deaths now occurring from eclamp-
sia and other complications of pregnancy and labor.
Intelligent treatment would also materially diminish the
number of dead-born babies, as it is well recognized that more
than one-half of such deaths are readily preventable. More-
over, many deaths in the first year of life would be pre-
vented, as the prenatal and obstetrical nurses would instruct
the mothers as to the importance of suckling their children,
and when that was impossible they would be put in the way
of receiving a proper supply of artificial food.
Blindness from ophthalmia neonatorum would also entirely
disappear, as every one connected with such a service would
employ as a matter of routine the prophylactic precautions
which practically absolutely prevent its occurrence. It is a
well-known, but regrettable fact that notwithstanding the pos-
session of such a prophylactic, the incidence of congenital
blindness shows no diminuation. In this way the ideals of
the Society for the Prevention of Blindness would be attained,
and large numbers of innocent persons would escape the
miseries of blindness, and the City and State would be spared
the burden of their expensive education of their maintenance
in blind asylums. Finally, the community would benefit by the
gradual disappearance of the midwife and the even more
dangerous ignorant physician.
All of these objects may be obtained by the annual expen-
diture of a sum of money sufficient to maintain 40 hospital
beds at the rate of $1.00 a day; while the community would
benefit by having fewer invalid women, many more well babies
and no blind ones.
DISCUSSION 203
The third point namely, the bearing of such a scheme upon
the proper education of medical students can be disposed of
more briefly. Generally speaking, obstetrics is the poorest
taught major subject in our medical schools. This is in great
part due to the fact that the lying-in hospitals connected with
them are too small to afford each student the oportunity of
delivering a sufficient number of patients under proper super-
vision to become a reasonably safe practitioner. I think that
I am safe in stating that the average medical student rarely
assists at more than five labors before graduation while at
least 20 or 25 are essential to a reasonable training. Under
such a plan as has been proposed each of the 300 students,
who each year obtain their obstetrical training in Baltimore,
could obtain the necessary experience and thus be put in the
way of becoming a competent practitioner.
It should, however, constantly be borne in mind that the
plan would fail to produce the best results unless it were con-
trolled by a broad-minded medical man who is interested not
only in caring for the women and their babies, but equally
so in advancing our knowledge of the generative processes of
women. One method would merely substitute male for female
rnidwives while the other would train a certain number of
persons to become scientific obstetricians and productive in-
vestigators. In other words, the scheme would fail to give the
best results unless it were in charge of men with true univer-
sity ideals, and would be foredoomed to failure if controlled
by politicians whether medical or otherwise.
Dr. S. Josephine Baker, New York: My experience with out-
patient clinics is limited. I want to endorse any movement
which will make for better care of mothers and babies in our
large cities. In New York City we have found that the so-
called "reformers" are exceedingly liberal towards this ques-
tion of baby-care. Whether or not the city would take up a
question of the magnitude described by the speaker is debat-
able. There is a tendency in most of our city governments to
assume more and more an attitude of so-called "paternalism"
in regard to child welfare movements and it is possible that
such a movement as this may come into being. When it does,
it will do a great deal to solve our vexed midwife question and
the problem of the poorly-trained doctor, which is a very serious
one in our large cities, and it will help to solve the problem
of the excessive death rate in infants from congenital debility.
Unless we can reduce this latter death rate we cannot make
very much more headway in the reduction of infant mortality.
204 THE IDEAL OBSTETRIC OUT-PATIENT CLINIC
particularly in those places where the decrease has been
marked during the past few years.
The Chairman: Dr. Fulton, of Louisville, will tell us some-
thing about this movement in Louisville.
Dr. Gavin Fulton, Louisville, Ky.: My experience along
these lines has not been very large, although I have been inter-
ested in the subject for a number of years, but owing to the
lack of funds it is only in the last few months that we have
been able to make any headway. We have the same difficulties
in raising money in Louisville for charitable or welfare pur-
poses that are experienced in other cities. For the last five
years we have been anxious to establish an out-patient obste-
trical clinic in Louisville in connection with our child welfare
work. I think that it is the most important phase of any in
reference to this work. For prenatal instruction and proper
obstetrical care of mothers certainly lessens the difficulties of
the problem of care and feeding during the first and second
nutritive periods. Wherever we go we hear protests against
the present inefficient obstetrical training of students and the
consequent incompetence of the medical profession in general,
particularly during the earlier years of practice in this branch
of medicine. It is a familiar cry that the doctor is not trained
but this cry is not followed by any proposition of practically
improving conditions. I hardly think the remedy can lie along
the line which I heard suggested at one of these meetings
in another city, which was as follows: To establish a six
months' training school for rnidwives. The product of such
a school would hardly be the superior in efficiency to a four-
year graduate of a reputable medical college. I think this
plan needs no comment. The ultimate hope in my opinion
is for those interested to talk less and be more active in their
demands and efforts to improve the clinical instruction of the
student. Theory supplemented by a few cases seen from the
benches cannot produce the foundation of a good obstetrician.
It seems to me that if out-patient obstetrical clinics were
established in connection with the infant welfare organizations
in which the schools were allowed to take their part at least
an attempt would be made in the remedy of these conditions.
As I have stated, about three months ago we made a modest
beginning along these lines. We have established in connec-
tion with the Babies' Milk Fund Association, an out-patient
obstetrical clinic which is held once a week in offices adjoining
the Milk Fund. The University of Louisville pays the slight
running expenses of this clinic and provides two students con-
DISCUSSION 205
stantly in residence who are present at the clinics and at each
delivery under the instruction and supervision of a member of
the medical staff who is a competent obstetrician. The Milk
Fund Association furnishes a nurse who does the prenatal
teaching in the homes under the instruction of the Medical
Director of the Babies' Milk Fund Association. At the end
of the tenth day after the birth of the baby it is enrolled by
the Milk Fund Association and its care and feeding are super-
vised by this Association from the very beginning, thus giving
us the opportunity of breast feeding in many instances where
this food would have been denied the infant and of exercising
the proper control of the artificial feeding where it is neces-
sary.
In conclusion, the establishment of these clinics offers facili-
ties for improving the teaching in the schools and the training
of ignorant expectant mothers in preparation for their future
off -spring. It further means more breast-fed babies and when
we have appreciably increased the number of breast fed babies
we have taken a large step in the lessening of infant mortality
and have also simplified the argument of how to feed them.
Dr. H. W. Bennett, Manchester, N. EL : We have a scheme for
eliminating the midwives in the smaller cities. Manchester's
industries are largely textile and shoe manufactories. They
employ between them about 23000 operatives. These opera-
tives are largely of foreign extraction French Canadians,
Germans, Greeks, Poles and other nationalities. The wages
paid are small, lower in the textile mills than in the shoe
factories. There were last year 2,149 births in the city. Of
these 94 were delivered by midwives, of which there are six
in our city. Two of those delivered one case each, one delivered
five, and the remaining three delivered 11, 28 and 48 respec-
tively. The midwife who delivered the highest number of cases
is the only one in whom we are very much interested. Next
year she leaves us seeking more lucrative fields. She is going
to New York City. The agency that has made her business
unprofitable is the District Nursing Association. The per-
centage of mothers who are unable to afford either a fam-
ily physician or hospital care is approximately 11 per cent,
of these 6.6 per cent have been delivered by the Nursing
Association and the remainder by midwives. The executive
head of the obstetrical department of the District Nursing
Association is a physician. Patients are required to pay
what they are able. The Metropolitan Life Insurance Co.
has cooperated with us paying for the mothers who are insured
206 THE IDEAL OBSTETRIC OUT-PATIENT CLINIC
in that company in its Industrial Department. In Boston
the criticism was made by Mr. Green that in this way we
were encouraging industrial insurance among the poor. We
think that criticism is not justified. In the first place in an
industrial center instalment insurance will prevail, whether
there is savings-bank insurance or not. The little work we did
will not increase in any way the amount of such industrial
insurance. We are simply taking care of those mothers who
would otherwise go to the midwives. Obstetrical service is
given by the younger men as they come to town. They are
looked up and their records gone over and if favorable, they
are requested to donate to the association their services sub-
ject to call for two or three months a year as the case may be.
The question was asked in Boston how we were able to secure
their services. It is simply a matter of custom. The older
men began donating their services at the organization of the
association and as their practice increased they simply asked
the younger men to do their share. Of course, there are
many things that an older man can throw to the younger men
in return. It also increases a new man's practice, and ulti-
mately it brings him in good standing with the older men and
gives him their stamp of approval in the community. The wage
that is paid in cities of this class is low. In Manchester the
operatives are employed a larger percentage of the year than
in any other shoe or textile city in America; this steady em-
ployment to some extent removes the problems of poverty that
some of the other cities have to deal with.
Dr. F. W. Pinneo, Newark: I have been greatly interested in
Dr. Newell's admirable paper and excellent outline for an ob-
stetrical out-patient clinic. Where a model school exists as at
Boston, to afford resources in workers it is the best plan yet or-
ganized. I am from Newark, a city of about 400,000 population,
which has a reputation to maintain for the extent and organi-
zation of its charities, and which knows the obstetrical problem
and seeks its solution. Dr. Williams' broad-minded remarks
have been very helpful. Dr. Bennett's report of the experience
of Manchester is still more applicable to Newark with a similar
population. We have no medical college nor medical students,
being so near both New York and Philadelphia. But such a
plan as Dr. Bennett commends shows how feasible is the han-
dling of the charity obstetrical cases by medical practioners
when properly organized. Dr. Williams' recommendation that
public funds are necessary suggests the possibility that our
Board of Health might lend aid to a plan which proved wisely
philanthropic and efficient. The speaker would be glad to
DISCUSSION 207
learn of the experiences of any other city which has a free
obstetrical out-patient clinic.
Dr. Henry Schwarz, of St. Louis; In America we are better
off in having started prenatal work sooner than other coun-
tries. We are much better off because of our excellent system
of nursing and the other branches of social service health work
that have developed within it and none is spreading much far-
ther or quicker. So the public at large will be much sooner
notified on that matter. But we are worse off on account of
the lack of state control than the old country. Much as Dr.
Williams admires the work he still insists that it is the work
of the community and the state. As to the work they are
doing in Manchester Dr. Bennett describes the Dispensary of
the Washington University when he outlines the Manchester
plan. We have in our Dispensary the work of the social service
department and the work of the prenatal nurse. We have
the women visited after delivery by the district nurses who are
in part paid by the Metropolitan Insurance Company. The
company pays fifty cents for each visit. We have many patients
who are not insured and the district nurse charges the same
price, fifty cents, for each visit. The Nurses' Association is
closely allied with the St. Louis Children's Hospital and when
the patients are discharged from our clinic, the children are
referred to the St. Louis Children's Hospital Dispensary.
Dr. S. Josephine Baker, of New York: I would like to report
the fact that by resolution of the Board of Health of New York
City, after January 1st, 1914, no woman who does not already
hold a license will be permitted to practice midwifery in the
City of New York until she has completed a course in a school
of midwifery registered as maintaining the necessary standard.
MATERNITY HOSPITAL CARE FOR THE WOMAN OF
MODERATE MEANS
GEO. W. KOSMAK, M. D., Attending: Snrgeon, Lyins-In Hospital,
New York City
There is a manifest and increasing tendency at the present
day among the laity to resort to hospitals in cases of illness,
especially if of a serious character, and the popular prejudice
against such institutions, formerly so prevalent, can no longer
be said to exist to the same extent as a few decades ago. The
growth of hospital accommodations has steadily increased
from year to year and whether poor or well-to-do, each pati-
ent can usually be provided for, according to his or her
means. Strange as it may seem, this applies less to maternity
hospital care than to any other, and although public and priv-
ate charities have provided to a fairly liberal extent for the
needs of the poor and the well-to-do, there are very scanty
accommodations for women who are able and willing to pay
a moderate fee for attention during their confinement in a
maternity hospital. A moderate fee for board, etc., might
arbitrarily be stated to range from $10.00 to $15.00 per week.
There are a large number of women who cannot be confined
in their homes at all, or only with difficulty, for reasons
about to be detailed. They may have to depend in pregnancy
on very inadequate medical and nursing attention and its dire
consequences. These patients are without the realms of the
pauper class and as they cannot obtain hospital accommoda-
tions within their means, they are often compelled to enter
the free wards of these institutions at a considerable disad-
vantage and detriment to themselves and their families.
Among them are often included the most self-respecting ele-
ment in the community; the wives of clerks, small store-keep-
ers, artisans, bookkeepers, and similar employees whose weekly
wages range from $15.00 to $30.00. Families of this kind may
be able to pay a moderate fee to a physician who would con-
fine them in their homes with the assistance perhaps of a "prac-
tical" nurse or another female member of the family. If all goes
well and the delivery is an uncomplicated one, the situation
may be satisfactory, but with the uncertainties attending a
first labor, or in other cases where complicating conditions
208
209
are present, the patient would be very much better off in a
hospital than to be confined in one of the small apartments
of the present day in which, of necessity, such people are
usually compelled to live. The modern apartment house which
supplies the housing needs of people in moderate circum-
stances, does not afford proper facilities for confinement and
neither does the furnished room or the boarding house which
many of these young married couples are obliged to resort to
in the first years of their wedded life. This condition un-
doubtedly is reflected in the birth-rate of this particular ele-
ment of the population in various ways. In the first place, the
lack of proper facilities and likewise the cost of proper atten-
tion, result in an attempt to avoid pregnancy or if conception
does result, notwithstanding such care, attempts will be
made to induce abortion. If young women could be afforded
a refuge during their confinement at this period of their lives,
it would undoubtedly greatly alleviate the terror with
which many of them look forward to childbirth, and often with
good reason. It may be truly said that the poor woman who
applies for attention during her confinement to the Out-Boor
Service of any one of our maternity institutions, will in the
case of trouble receive better care and attention than the pros-
pective mother somewhat better situated financially, who en-
gages a physician to attend her and who may in the course of
the labor find it necessary to summon assistance. Unfortu-
nately, obstetrical standards among many members of the
profession are not high enough to compel them to have a prop-
er equipment for the delivery of such cases and thus a great
burden often falls on another physician who may be called in
after a prolonged and tedious labor or other accidents which
demand operative delivery. Skilled assistance is very essen-
tial under these circumstances if the life of the child and very
often the mother is to be saved.
It would, therefore, be for the woman's individual good, for
that of physicians as a class, and also that of the community,
if people of moderate means could be provided when necessary
with the proper hospital facilities at rates within their means.
This also applies to those who are compelled to leave a temp-
orary home because confinement under such circumstances un-
doubtedly causes many women to seek hospital aid or in some
cases, the knowledge that it may be obtained without cost, spurs
them on to make use of such facilities. This state of affairs is,
of course, entirely wrong, for when such families have once
experienced the advantages accruing from hospital care, the
fact that they have obtained them for nothing, does not dis-
210 MATEBNITY HOSPITAL CARE
turb them. In a certain sense they have pauperized themselves
and kept a more worthy applicant out of the bed which was
thus occupied. I think it is quite generally credited among
those whose practice brings them into contact with large ma-
ternity service, that many women apply with the idea of pay-
ing a 'small fee for their hospital accommodation. They do
not wish to be included among the charity patients and yet
their environment is such that in most instances a delivery
would be accompanied with unpleasant or even dangerous con
sequences. Such women have no desire to go into the free
wards for obvious reasons, and it is most unfortunate that
they must be turned aside because the only other alternative
ordinarily offered to them is a private room at f 25.00 or more
per week, a sum far beyond their means. On the days when
I have charge of the antepartum work at the Lying-in Hos-
pital, scarcely a day passes when this request is not made.
What finally becomes of these patients when we turn them
aside I do not know, as there are very few facilities offered
ia New York City for their accommodation. In desperation
they finally allow themselves to be admitted at one institu-
tion or another as free patients, and when once they have re-
ceived such benefits free from financial obligation, they will
be led to resort to the same on future occasions and when
once the start has been made they will always be more or less
of a burden on the hospital and so indirectly on the com-
munity. Moreover, at the present time we meet with a large
and constantly growing class of people who from force of cir-
cumstances can never elevate themselves much above the fin-
ancial status which they occupied at the beginning of their
married life, for the chances of advancement for many em-
ployees in mercantile establishments are not very favorable
and although one out of ten may succeed in advancing himself
to a position of greater responsibility and financial return, the
other nine remain approximately at the same level. Such
people, however, should be made to retain their self-respect
and no where it seems to me, is this lost more quickly than in
extending to them absolutely free hospital care. They should
be made to pay and they are usually very glad to pay a mod-
erate fee for these services.
There is another feature in connection with the residence
of obstetrical patients in a hospital which is of great impor-
tance; namely, the opportunities which all of these women
would have of observing the manner in which they and their
babies are cared for. This is a most valuable object lesson and
thoroughly in accordance with the ideas of the present timer
GEORGE W. KOSMAK, M. D. 211
In order to determine what facilities are offered by matern-
ity hospitals In general for the care of women in moderate
circumstances the writer has made a partial canvas among
such institutions, which is not intended to be complete, but is
yet sufficiently so to afford an idea of what has been provided
in this direction. A questionaire containing requests for the
information noted below, was sent to a number of obstetricians
connected with the leading maternity hospitals in the United
States and herewith I desire to express my obligation to those
who kindly furnished me with the desired facts. The questions
were as follows :
1. Does your institution provide obstetrical care for pati-
ents who are able to pay a hospital fee of from $10.00
to $15.00 per week?
2. If so, what facilities do you provide for this service?
Number of beds, wards, rooms, etc. ?
3. Is the hospital or the attending physician permitted to
charge a fee for attendance on these cases?
4. If the provisions referred to exist in your institution,
what are the results as regards the number of pati-
ents and the financial return? Has the system paid?
5. From your personal experience in the matter, do you
favor a retention or extension of such a system of
special wards for patients in moderate circumstances?
For lack of time and other reasons, the inquiry was neces-
sarily limited in its range, but sufficient knowledge has been
obtained by this means to permit us to form a fairly satisfac-
tory judgment of the situation as it exists today. A total of
thirty-one institutions is included in this report, stretching
across the Continent from Boston to San Francisco. In only
nineteen of these can patients be accommodated at rates of
$15.00 per week or less, although the proportion of such beds
in each of these hospitals is apparently sadly inadequate. The
exact number of beds available cannot be stated, as in several
of these hospitals a fee for the same is only collected when
the patient is able or willing to pay. Accommodations at less
than $15.00 per week are usually in wards, although in some
institutions two or three patients can be accommodated in a
single room.
At this point it may be well to summarize the replies re-
ceived from the various institutions to whom the questionaire
was sent.
212 MATERNITY HOSPITAL CAEE
Dr. F, S. Newell, of the Boston Lying-in Hospital, states
that this institution admits all patients living in Boston for
|20.00, or such part as the patient can pay. This admission
fee covers the entire charge for board and treatment. There
are three wards of nine beds, and three wards of six beds
each, no private rooms being provided. He states that they
lose money on every patient, and probably one-third of the
cases are free or pay less than $10.00.
Dr. A. K Paine, of the Mount Sinai Hospital, in Boston,
stated that they had no facilities for caring for this class of
patients. He informs me that there are a number of semi-
private institutions in Boston in which the minimum charge is
from $15.00 to $20.00 per week, but none which confined an
obstetrical case for a maximum fee of from $10.00 to $15.00.
Dr. Henry D. Frey, of the Maternity Department of the
Georgetown University Hospital, in Washington, states that
they have rooms with two beds at $15.00 per week and three
wards containing forty beds, for which $1.00 per day is
charged. The attending physician is allowed to charge a fee
in these cases, but if delivered by the house-staff, there is no
charge. He states that $10.000 per week just meets the expense
of each patient and a charge of $1.00 per day in the ward
beds, a loss of 26 cents.
Dr. A. B. Spalding, of the University Hospital of San Fran-
cisco, states that they have one ward of eight beds, for which
a fee is charged, but that they intend shortly to extend this
service to forty beds at $10.00 per week each, with no profes-
sional fee,
Dr. W. J. Maroney, of St. Anne's Maternity Hospital, in
New York City, writes that they have three double rooms at
$15.00 per week and a small ward containing seven beds at
from $9.00 to $10.00 per week, in all of which the attending
physician or the hospital is permitted to charge a fee.
Dr. Elizabeth Jarrett, of the New York Medical College and
Hospital for Women, stated that they have two rooms of two
beds each, for which the charge is $12.00 per week and a fee
of $5.00 for the operating room. Only their own alumni have
the privilege of sending patients into these special rooms. Oc-
casionally they put such cases in the larger wards in which
there are six or eight beds. The attending staff is permitted
GEORGE W. KOSMAK, M. D. 213
to charge from f 15.00 to $25.00 in each case. Dr. Jarrett states
that although not at first used for clinical material, the pati-
ents now seem to have no objection to the same,
Dr. G. L. Brodhead, of the Post-Graduate Hospital,
York City, reports that they have a ward of eight beds for
such patients,, although comparatively few pay for these accom-
modations.
Dr. J. 0. Polak, of the Long Island College Hospital, in
Brooklyn, states that they have four beds at ?10.00 and four at
$14.00 each, and the attending physician is permitted to charge
a fee in these cases. These accommodations are always occu-
pied and they plan to extend the system.
Dr. J. W. Williams, of Johns Hopkins, writes that all pati-
ents are expected to pay what they can, it being estimated
that $10.00 per week covers the cost of a patient in the free
wards. He assumes that 25 per cent of their ward patients
make such payment, although they are treated exactly as the
free patients and are used for clinical instruction. The at-
tending physicians are not permitted to charge a fee in such
cases. Dr. Williams considers that the greatest need in mod-
ern hospitals, is provision for self-respecting patients who are
only able to pay small fees. Such patients must be taught
that they are objects of charity and are not paying their own
way, for he believes that unless private patients pay at least
$25.00 per week, they are a distinct loss to any hospital.
Dr. H. T. Button, of Zanesville, Ohio, states that in the
local hospital, which may be taken as an example of what
pertains in similar small communities, they have private wards
and rooms in which the charge is less than $15.00 per week,
with two patients each, and although the system does not pay,
he believes in its continuance in his community. He reports a
total of forty-five women thus confined from January 1st to
September 20, 1913.
Dr. 0. H. Humpstone, of Brooklyn, states that at the Meth-
odist Hospital they have one ward of four beds at $15.00 per
week, and at the Jewish Hospital they have one ward with six
beds at $10.00 per week. In both institutions the attending
physicians are permitted to charge a nominal fee. He believes
that the system pays because of the self-respect engendered in
such patients and the good care given them, that it likewise
adds a little to the income of the attending physician from a
214: MATERNITY HOSPITAL CARE
class of patients from which he probably would not otherwise
receive any fee. He states, moreover, that the superintendent
of one of these hospitals says that he would be glad to develop
a service for this class of patients, whereas the superintendent
of the other plainly states that he is not In favor of private
wards for maternity cases and that these should be confined
at home, on the theory that they do not add to the financial
success of the institution and block the beds for poor charity
cases, the care of which is the first purpose of our hospitals.
I might add by way of comment that the latter view is incor-
rect from every economic and medical viewpoint. A modern
hospital should certainly occupy a different standing in the
community.
Dr. A. A. Hussey, of the Brooklyn Hospital, reports that
this institution has only one two-bed ward at f 12.00 each and
one small room at |15.00. A small fee may be charged by the
attending physician for these cases. There is demand for more
beds of this kind than can be supplied, and Dr. Hussey writes
that in their new hospital they will provide for three or four
times the present number.
Dr. John Wyeth, of the New York Polyclinic Hospital, states
that they have two private wards containing five beds each,
for which f 15.00 per week is charged. The system has been in
operation too short a period to permit any deductions, but Dr.
Wyeth is in favor of a retention and an extension of the same.
Dr. P. W. Van Pemyea, of the General Hospital, in Buffalo,
reports two wards of ten beds each, for which $8.00 per week
is charged.
Dr. Austin Flint,Jr., of the Manhattan Maternity Hospital,
in New York City, stated they had three wards with six beds
each, for which a fee of f 10.00 was charged. He believes that
the lack of such accommodations is to be greatly regretted and
the same should be extended.
Dr. Edward P. Davis, of the Jefferson Hospital, in Phila-
delphia, is strongly in favor of enlarging the system as much
as possible. They only have two beds in one room, at $10.00
each.
Dr. F. J. Taussig, of the St. Louis Maternity Hospital, re
ports that in this institution there are two wards with twelve
GEORGE W. KOSMAK, M. B. 215
beds each, for which a moderate fee is charged. He is decid-
edly in favor of an extension of the system.
Dr. J. B. DeLee, of the Chicago Lying-in Hospital, states
that in the new hospital, now under construction, there will
be fifty beds at moderate prices, although there are only seven
in the present building. Notwithstanding that there is no
profit in this system, which costs $2.50 per day per patient,
he is in favor of the extension of the same.
Dr. Thomas Watkins, of St. Luke's Hospital, Chicago, states
that they have seventeen beds at rates of less than f 15.00 per
week. A loss is claimed on every patient ? which must be met
from other sources of income; nevertheless, he is in favor of
extending the system.
Dr. W. P. Manton, of the "Woman's Hospital, in Detroit,
writes that they have no special facilities for cases able to
pay a moderate fee and that the patients pay whatever they
can afford. He is thoroughly in accord with the necessity for
providing accommodations for this class of cases.
Dr. Henry Schwarz, of St. Louis, reports that in the new
hospitals of Washington University, thirty-six ward beds will
be provided, for which a fee of fT.OO per week will be asked,
and about eight rooms at f 15.00. At St. Ann's Maternity, in
the same city, there are twenty-four rooms, ranging in price
from |12.00 to flS.OO per week. Although the system does
not pay, he believes that if a hospital will make this a lead-
ing or exclusive feature, it can be made to pay. Moreover, he
believes that to provide at reasonable cost, hospital care for
people of moderate means, seems the truest form of charity.
The care of the sick poor on the other hand, is plainly the duty
of municipal institutions.
The Providence Lying-in Hospital provides accommoda-
tions for patients at the rate of $20.00 for two weeks, which
includes attendance during the confinement and the patient's
board. The wards contain five beds for this class of patients.
In addition to the above, letters sent to other well-known
gynecologists and obstetricians disclose the fact that no pro-
vision whatever for caring for this class of patients is made
in institutions with which they are connected. One and all,
however, have expressed themselves in favor of the introduc-
tion and development of a system of this kind. We find, for
216 MATERNITY HOSPITAL CARE
example, that the Lying-in Hospital, and the Sloane Matern-
ity Hospital of New York City, which are among the largest
and best equipped maternity institutions in this country, fail
to make any provision whatever for pay patients in moderate
circumstances.
An inquiry of this kind could doubtless be extended with
similar replies from other institutions, but it may be assumed
that for practical purposes, the above is sufficient to call at-
tention to the desirability for further agitation and study of
this important question.
In an attempt to solve this problem a number of factors
must be taken into consideration. We have to deal in the
first place with the attitude of the physician in general prac-
tice towards a scheme of this kind, and we must also ap-
proach the question from the standpoint of the hospital, as
to whether such facilities can be economically provided and
not interfere with the remainder of the work in the institu-
tion. Eegarding the first point, there is no doubt whatever but
that the average physician would benefit in the end by this
scheme of providing proper hospital care for certain classes
of his patients. The nursing question is a most important one
in this connection, as the physician must usually rely on a so-
called practical nurse in such cases, whose ministrations both
to the mother and baby are more often based on hearsay and
personal experience, rather than on any definite training.
Especially in the case of a primipara with possible pelvic con-
tractions* or other complicating features is a labor under cer-
tain home conditions to be looked forward to with satisfac-
tion. The larger proportion of labors at the present day are
not strictly physiological and complications are unfortunately
all too frequent. If a physician could observe and study a
case of pregnancy in the "presence of possible complications
and could feel assured that if necessary his obstetric patient
would be properly taken care of in a hospital, and returned
to him without having been pauperized by free treatment, it
would seem as if his own standing was considerably improved.
As already stated, each community must solve its individual
medical problems and a scheme of supplying this class of ob-
stetric service in one community would not be adapted to that
of another. The question is one which will require gradual
elucidation and working out, but for the present, provision
might be made by the existing hospitals to provide service of
this kind. Our inquiry showed us ? for example, that such
MATERNITY HOSPITAL CABE 217
large institutions as the Lying-in and the Sloane Maternity
Hospitals, of New York, make absolutely no provision for this
class of patients, although in each of them, private rooms
are provided for people who can pay thirty dollars or more
a week for their accommodations. The only other alternative
is to have the women in these and similar institutions in mod-
erate circumstances who may choose or require hospital care,
go into the ordinary ward, which, for obvious reasons, will not
prove suitable or satisfactory to the class of patients here
under consideration. Most hospitals admit that the bed at
?10.00 per week is not a paying venture. This, however, ought
not to weigh in the scale against the adoption of a system of
this kind, as the income would certainly be enough to pay the
greater part at least of such expense.* Again, if viewed in
another light, it would perhaps show a profit if we compared
this with the cost of a patient in the free ward for which
there would be absolutely no financial return.
The objection may be made that provision for providing
obstetric hospital facilities with the possibility of a deficit,
will invade the field of philanthropy, but if this is done in
order to furnish beds for the care of ordinary surgical or med-
ical cases, why should it not be extended to include preg-
nancy? Patients presenting the after-effects of accidents or
complications of labor and the puerperium, many of which
may be included under the head of plastic and reparative
operations, find a ready domicile in our hospital wards for
a moderate fee, but the self-respecting woman who desires to
pay a small sum for her care in a hospital because she needs
its assistance for one reason or another, finds it impossible in
many instances to secure the same. Such a state of affairs
may justly be regarded as the height of inconsistency.
BEPOBTS
NEW ENGLAND SUB- COMMITTEE ON OBSTETRICS
JAMES LINCOLN HUA'TINGTON, M. D., Boston, Secretary
The attempt was made this year to make a thorough canvass
of the following obstetrical conditions as they exist in the
six states of New England :
A. The status of obstetrical education in the medical schools
B. Standards of obstetrics in actual practice
C. The activity of the midwife
In this attempt we have been only partially successful. In
the following contributions from the individual members of
the committee it will be seen that many of them have been
doing pioneer work, and these results form the most impor-
tant part of this report.
There are at the present time eight medical schools in New
England, one, Dartmouth, has discontinued its clinical courses,
and the granting of the degree of M. D. One is not recognized
by the Massachusetts Medical Society and is ranked in the
lowest class of existing medical schools by the American
Medical Association. Of the remaining six we have obtained
reports from five.
A. STATUS OF OBSTETRICAL EDUCATION IN THE MEDICAL
SCHOOLS
MAINE
Bowdoln Medical School
Obstetrics is taught at the Bowdoin Medical School by a
lecture course during the third year of three lectures a week.
One quiz by the assistant and a supplementary course in sec-
tions, on the manikin 7 during the spring term. No definite
number of cases is required at present, but a certificate is re-
quired from each student that he has taken an out-patient
course in some lying-in hospital of at least two weeks 7 dura-
tion. At present there is an arrangement with the out-patient
department of the Boston Lying-in Hospital whereby men are
taken the summer after they have completed their theoretical
work and most of the students at Bowdoin since the arrange-
ment went into effect have availed themselves of this oppor-
tunity, although some of the men get their required two
218
JAMES LINCOLN HUNTIXGTON, M. D. 210
weeks' service elsewhere. There is a "temporary home*' in
Portland where about twenty-five or thirty-five women are
delivered during the year. The normal cases are delivered by
the students under supervision and they observe the operative
cases if any occur. Here they also have an opportunity to
make ante-partum and post-partum examinations. There is
an out-patient clinic in Portland which is just being started,
ten cases being delivered by students under supervision last
year.
MASSACHUSETTS
Boston University School of Medicine, Department of Obstetrics
Boston University School of Medicine has always had a well-
grounded as well as comprehensive course of obstetrics in it^
school. The department offers students unparalleled oppor-
tunities to familiarize themselves with this important branch
of medicine.
The didactic teaching extends over two full years, with
numerous quizzes and frequent demonstrations during the
second and third years of study. During the first year's work
in obstetrics, in addition to the didactic portion, the student
is required to attend the maternity clinics at the Out-Patient
Department of the Massachusetts Homoeopathic Hospital,
open daily, in which are treated all diseases pertaining to preg-
nancy, examinations held of obstetric cases and suitable pre-
scriptions given therefor.
During this year, the students in sections attend the ex-
aminations of patients in the obstetric department of the hos-
pital. Thorough demonstration is given in hygiene and man-
agement of the cases of pregnancy, palpation, pelvimetry and
the actual bedside teaching of the puerperium and conditions
pertaining to the new-born child.
Clinics with demonstration of actual cases are held at which
both years' students are in attendance.
During the year, one student may attend with an older
student in the outside work of the dispensary.
The second year's study includes demonstrations of opera-
tive work in obstetrics, clinics at the hospital, and at, or near
the completion of the lectures, the student is given bedside
instruction with the actual work done in taking care of pa-
tients at their homes in the district. The minimum number of
cases attended by any senior student during the past year was
REPORTS
NEW ENGLAND SUB-COMMITTEE ON OBSTETRICS
JAMES LINCOLN HUNTINGTON, M. D., Boston, Secretary
The attempt was made this year to make a thorough canvass
of the following obstetrical conditions as they exist in the
six states of New England :
A. The status of obstetrical education in the medical schools
B. Standards of obstetrics in actual practice
C. The activity of the midwife
In this attempt we have been only partially successful. In
the following contributions from the individual members of
the committee it will be seen that many of them have been
doing pioneer work, and these results form the most impor-
tant part of this report.
There are at the present time eight medical schools in New
England, one, Dartmouth, has discontinued its clinical courses,
and the granting of the degree of M. D. One is not recognized
by the Massachusetts Medical Society and is ranked in the
lowest class of existing medical schools by the American
Medical Association. Of the remaining six we have obtained
reports from five.
A. STATUS OF OBSTETRICAL EDUCATION IN THE MEDICAL
SCHOOLS
MAINE
Bowdoin Medical School
Obstetrics is taught at the Bowdoin Medical School by a
lecture course during the third year of three lectures a week.
One quiz by the assistant and a supplementary course in sec-
tions, on the manikin, during the spring term. No definite
number of cases is required at present, but a certificate is re-
quired from each student that he has taken an out-patient
course in some lying-in hospital of at least two weeks' dura-
tion. At present there is an arrangement with the out-patient
department of the Boston Lying-in Hospital whereby men are
taken the summer after they have completed their theoretical
work and most of the students at Bowdoin since the arrange-
ment went into effect have availed themselves of this oppor-
tunity, although some of the men get their required two
218
JAMES LINCOLN HUNTINGTON, M. D. 219
weeks' service elsewhere. There is a "temporary home" in
Portland where abotit twenty-five or thirty-five women are
delivered during the year. The normal cases are delivered by
the students under supervision and they observe the operative
cases if any occur. Here they also have an opportunity to
make ante-partum and post-partum examinations. There is
an out-patient clinic in Portland which is just being started,
ten cases being delivered by students under supervision last
year.
MASSACHUSETTS
Boston University School of Medicine, Department of Obstetrics
Boston University School of Medicine has always had a well-
grounded as well as comprehensive course of obstetrics in its
school. The department offers students unparalleled oppor-
tunities to familiarize themselves with this important branch
of medicine.
The didactic teaching extends over two full years, with
numerous quizzes and frequent demonstrations during the
second and third years of study. During the first year's work
in obstetrics, in addition to the didactic portion, the student
is required to attend the maternity clinics at the Out-Patient
Department of the Massachusetts Homoeopathic Hospital ?
open daily, in which are treated all diseases pertaining to preg-
nancy, examinations held of obstetric cases and suitable pre-
scriptions given therefor.
During this year, the students in sections attend the ex-
aminations of patients in the obstetric department of the hos-
pital. Thorough demonstration is given in hygiene and man-
agement of the cases of pregnancy, palpation, pelvimetry and
the actual bedside teaching of the puerperium and conditions
pertaining to the new-born child.
Clinics with demonstration of actual cases are held at which
both years' students are in attendance.
During the year, one student may attend with an older
student in the outside work of the dispensary.
The second year's study includes demonstrations of opera-
tive work in obstetrics, clinics at the hospital, and at, or near
the completion of the lectures, the student is given bedside
instruction with the actual work done in taking care of pa-
tients at their homes in the district. The minimum number of
cases attended by any senior student during the past year was
220 BEPOBT
ten, the number frequently reaching fifty or more. Before
graduation, all students are required to furnish satisfactory
written reports of at least six obstetric cases attended per-
sonally by them.
At all stages, the student is led to observe the necessity for
careful work and its tremendous importance to the future
lives of both mother and child.
To the student or the graduate desiring more specific in-
struction or opportunity for work and observation, the school
with its faculty and the hospital with its staff, are both ready
and anxious to serve.
The imprint of the importance of the obstetrician and his
work, given to the medical student, will in time reveal itself
in the acceptance and the demand for nothing but the best
that can be given the mother and her new-born infant.
BOSTON (Continued)
Tufts College, Department of Obstetrics
Prof. L. V. Friedman reports as follows: The Department
of Obstetrics at Tufts requires of the third year students, at-
tendance at two lectures and one recitation weekly throughout
the school year. Each student must attend six women in con-
finement and write full reports of the labors and convales-
cences. In the past year most of the students had seven or
eight cases and some had as many as fourteen. While engaged
in this work, they see the common obstetric operations, per-
formed by instructors from the school.
In the fourth year each student receives instruction, in
small sections, in operative obstetrics. This course is given
on the manikin and each student performs all of the common
operations under the guidance of the instructor.
Harvard Medical School
Dr. E. L. De Normandie of the Department of Obstetrics
reports as follows: Instruction in obstetrics in the Harvard
Medical School is given by didactic lectures, conferences and
clinical teaching. The teaching staff consists of the professor,
the assistant professor and instructor, four assistants and an
alumni assistant. None of these men give up their entire
time to teaching. This year for the first time will didactic
lectures be given to second year students one lecture a
week during the second half year. In the third year lee-
JAMBS LINCOLN HUNTINGTON, M. D. 221
tures are given twice a week during the first half-year and
once a week during the second half-year. During this year
the students in turn are assigned to duty in the out-patient
department of the hospital for periods of 10 days. All
students are required to take charge of at least 6 cases of
labor under supervision and instruction, to care for these
cases during the convalesences and to make full written re-
ports of these cases. Many of the students look after from 20
to 30 patients. Conferences twice a week are held by the
assistants with the students when the problems which come
up in their daily work are informally discussed. The fourth
year offers an elective course in obstetrics. In this course the
students live at the hospital the first part of the month and
look after the cases as they come in. When they are not busy
during the morning the stadents make the visit with the phy-
sician on duty at the hospital and the problems which arise
in the wards are fully and carefully discussed by the physician
and students. The convalesence is followed by them the same
as in the third year. Operative obstetrics is taught the stu-
dents by five two-hour exercises at the medical school as a
part of the fourth year work, besides their seeing many opera-
tive deliveries by the hospital staff. A large percentage of the
fourth year students elect this course.
c cxonEc CTICUT
Vale Medical School
Prof. Eamsey of the Yale Medical School states that the re-
quired course in obstetrics includes four lectures a week for
one of the two terms in the junior year, with some six demon-
strations on the manikin during that year, a term of service at
the dispensary during the senior year, delivering at least
six patients in the out-patient department under observation.
This number of cases varies somewhat but rarely exceeds ten
unless a student spends part of his summer vacation in the
dispensary when he may deliver as many as twenty cases.
While on service in the out-patient department he has an op-
portunity to measure and examine the cases as they apply for
treatment in the pregnancy clinic. During the fourth year
the student also has some six exercises on the manikin in
operative obstetrics. The out-patient department cares for
some 200 cases during the year. Oases are supposed to report
to the out-patient department and be examined in the preg-
nancy clinic after which they report monthly or oftener if
necessary.
222 REPOET
B. CONCER1VING STANDARDS IN ACTUAL, PRACTICE
Your committee through its activities succeeded in prevent-
ing the passage of a bill before the Massachusetts legislature
to provide for the registration of midwives. The committee
has also been instrumental in presenting the following resolu-
tions to the Council of the Massachusetts Medical Society to
clearly define the policy of that organization with regard to
the practice of obstetrics. These resolutions have already
been endorsed by the staff of the Boston Lying-in Hospital,
the Boston Obstetrical Society, the Department of Obstetrics
in Tufts University, as well as by many physicians, not only
in Boston but in other parts of the State of Massachusetts.
WHEEEAS, by Chapter 76, sections 8 and 9, of 'the Revised Laws of
the Commonwealth of Massachusetts, the midwife was excluded from
the practice of her profession within the confines of this state and by
a decision of the Supreme Court handed down by Justice Rugg in the
case of the Commonwealth vs. Porn the law was held to directly cover
the activities of the midwife and made effective.
And whereas Chapter 29 of the Revised Laws of the Commonwealth
of Massachusetts repeatedly uses the word Midwife (Section 3, "Physi-
cian and midwife shall make and keep a record, etc.," and later "the
fee of the physician or midwife shall be twenty-five cents, etc.," and
later "the physician or midwife who neglects, etc.,") thus seeming to
give her legal status.
And whereas by House Bill 678 presented to the Great and General
Court of the Commonwealth of Massachusetts January 9, 1913, a defi-
nite, although unsuccessful attempt was made to legalize the mid-
wife and admit her on equal terms with the physician to the practice
of obstetrics, this bill being favored by certain members of the Massa-
chusetts Medical Society.
And whereas persistent reports are being received that members of
the Massachusetts Medical Society are signing birth returns of infants
delivered by midwives without a physician in attendance.
Be it Resolved that we, the Council of the Massachusetts Medical
Society, put ourselves on record as of the firm opinion that the practice
of obstetrics is a vital and essential branch of the practice of medicine
and requires the care and supervision of a graduate in medicine and
that there is no place for the untrained practitioner in this field of
medicine within the Commonwealth of Massachusetts, that no training
other than that leading to the degree of M. D. is to be considered ade-
quate or sufficient for engaging in this practice, that untrained persons
practicing obstetrics are in open defiance of the law and should be
prosecuted when apprehended. That as soon as public sentiment within
and without this society can be sufficiently aroused a bill shall be
presented to the Great and General Court of the Commonwealth of
Massachusetts which shall provide for the omission of the word mid-
wife from the statute books thus bringing the law up to the date; that
members of this society are hereby enjoined from handing in birth
returns on cases over which they have had no supervision when de-
livered by a midwife; and that it is the opinion of this body that a
physician signing a birth return assumes the responsibility for that
case.
JAMES LINCOLN HUNTINGTON, M. D. 223
* SUPPLEMENTAL REPORTS
PRENATAL AND POSTNATAL WORK, DEPARTMENT OF HEALTH
Boston
Prenatal and postnatal work are done by the Division of
Child Hygiene, a department within the Board of Health.
Prior to June, 1912, two nurses were engaged in this work.
The utter futility of trying to cope with existing conditions
with such a corps of nurses was soon apparent and a request
was made for more nurses.
Accordingly, in June, 1912, the corps of nurses was increased
to ten. The city was divided into districts and the nurses
were assigned as follows :
Ward 1 and 2, one nurse. "Wards 13, 14 and 15, one nurse.
Wards 3, 4 and 5, one nurse. Wards 16, 20 and 24, one nurse.
Ward 6, two nurses. Wards 17, 18 and 19, one nurse.
Wards 7, 9. 10 and 12, one nurse. Wards 21, 22, 23 and 26, one nurse.
Wards 8, 11 and 25, one nurse.
Owing to the rapid approach of hot weather and the result-
ing increase in the number of cases of enteric disease among
babies, all efforts were concentrated on post-natal work. The
home of every baby born in Boston was visited by the nurses
and information and advice given on the value and importance
of breast feeding. Naturally, the bulk of our work was
among the bottle-fed babies of the poor. Repeated visits were
made to these babies during the summer months and every
effort made to see that they were fed under medical super-
vision.
In October, 1912, prenatal work was resumed on a much
larger scale. During the preceding four months, the nurses
had covered the whole city in their postnatal work and had
established a clientele among whom prenatal work was re-
sumed. Monthly visits were made to expectant mothers and
a friendly relation established between the nurse and the
patient. Advice on the care of the breasts, on diet, and on
matters of personal hygiene was given on these visits and an
examination of the urine made.
The following card was used to record the work of this
sub-division.
* See pages 187-190 for report of Prenatal Work of Committee on Infant Social
Service of the Women's Municipal League of Boston.
224:
REPORT
DIVISION or CHILD HYGIENE PRENATAL
Name Age Address Ward
PREVIOUS PREGNANCIES
Number
PRESENT PREGNANCY
Duration
Stillborn
General Health
Miscarriage
Attendance
Attendance
Feeding
RECORD OP VISITS
Date
Condition
Urine
Oedema
B. Pressure
V. Veins
CONFINEMENT
Date
Attendance
Result j Condition
Mother BabyiMother Baby
Feeding
Sex
.Nurse
DIVISION OF CHILD HYGIENE FAMILY
Name Address
HUSBAND
Character
Character
WIFE
Occupation
Occupation
Nationality
Nationality
Age
Age
CHILDREN
Number Living
Number of
HOUSING
Rooms
Ages
Condition
Number Dead
Boarders
JAMBS LINCOLN HUNTINGTON, M. D. 225
The following tables show the amount of work done from
June, 1911, to December 31, 1912 :
PRENATAL
Attendance. Feeding
No. Cases 885 Physician 60 Breast-fed 322
No. Visits 1,716 Hospital 134 Bottle-fed 51
No. Babies Born 413 Midwife 219 Breast and bottle-
fed 40
POSTNATAL
Feeding
No. Cases 17,429 Breast-fed 13,129
No. Visits 41,001 Bottle-fed 2,703
Breast and Bottle-fed. . . . 1,597
Although the year 1912 showed an encouraging reduction
in infant mortality in Boston, plans were made early in the
spring of 1913 for more intensive work. Ten additional nurses
were appointed in June, 1913, for a period of four months,
making a corps of nineteen nurses. Prenatal work was again
suspended during the summer months and every energy di-
rected toward lowering the death rate among babies.
The following tables show the amount of work done for the
period January 1, 1913, to October 1, 1913:
PRENATAL
Feeding Attendance
No. Cases 223 Breast-fed 62 Physician 40
No. Visits 413 Bottle-fed 5 Hospital 23
No Babies Born. . 70 Breast and Bottle- Midwife 7
fed 3
POSTNATAL
Feeding
No. Cases 13,327 Breast-fed 10,323
No. Visits 38,337 Bottle-fed 2,017
Breast and Bottle-fed 987
The most encouraging information to be gleaned from the
prenatal tables is the decline in midwife attendance. We at-
tribute this decline to the personal influence of the nurse,
who has been able to convince expectant mothers that their
future was more secure in the hands of a physician.
The encouraging news, due to postnatal activity, is that
the death rate among infants for the four summer months,
June to September, 1913, was the lowest in Boston's history.
226 REPORT
The following table shows the death rate under one year
per 10,000 inhabitants, from 1900 to 1913 (1913 is for the first
9 months) :
1900 42.96 1905 36.72 1910 33.38
1901 40.28 1906 40.43 1911 32.63
1902 39.27 1907 37.57 1912 30.36
1903 37.36 1908 42.81 1913 29.91
1904 37.50 1909 32.42
I desire here to call attention to the message of his Honor
the Mayor to the City Council, recommending an appropria-
tion for additional temporary nurses :
CITY OF BOSTON
Office of the Mayor, June 23, 1913.
To the City Council:
I beg to transmit herewith a communication from the trus-
tees of the Milk and Baby Hygiene Association, under date of
June 9, urging the appointment of ten additional nurses for the
Department of Child Hygiene, at least during the summer
months.
I am informed that of the 20,000 babies born in Boston dur-
ing the past year 2,136 of this number died before reaching the
age of one year, and that 75 per cent of this number of deaths
were preventable, I am further informed that the high death
rate among infants under the age of one year is due" to lack
of information on the part of mothers. Previous to a little
over a year ago all efforts to assist mothers in caring for their
babies were confined to private charities. Last June, in the Divi-
vision of Child Hjcgiene, ten nurses were appointed. These
nurses attempted to cover the whole city and to assist mothers
in the care of infants. Considering the small number of nurses,
very efficient results were accomplished and the death rates
among infants was materially reduced.
I heartily agree with Doctor Gallivan, the director of the
Division of Child Hygiene, that work of this nature is as impor-
tant a function of government as the police, fire and school
activities, and I therefore earnestly recommend the passage of
the accompanying order transferring the sum of $2,250 from the
Reserve Fund to an appropriation to be expended under the di-
rection of the director of the Division of Child Hygiene of the
Health Department, to provide for the appointment of ten tem-
porary nurses for a period of three months.
Respectfully,
JOHN F. FITZGEEALD, Mayor.
Such recognition of this work which has formerly been
wholly done by private charities augurs well for the awaken-
ing of the public conscience, and is a well deserved tribute to
the pioneers who have blazed the trail, and have waged cease-
less war on customs, practices and methods which are respon-
sible for the high death rate among babies.
OBSTETRIC CAKE OJP THE MAVERICK DISPENSARY
East Boston, 31 as*.
A. B. EMMOXS, 2nd, M. D., Physician-ln-Chief
How could complete obstetric care be furnished to the poor
of a community at cost within the means of almost any pati-
ent, and yet be nearly, or entirely self-supporting? This was
the problem which we hare attempted to solve in one city
section.
East Boston presented an almost isolated community of
about 60,000 inhabitants, roughly, one-half being foreign,
largely Italian, with many recent immigrants. We have no
medical students to care for the normal cases and no oppor-
tunity to teach.
The following scheme was evolved and is now in operation.
The patient applies at the dispensary. Her social history
is taken at the admission desk by our social worker. The
patient is asked to pay -|5 at the time of registration, usually
at this visit, occasionally, at a subsequent visit. After con-
finement another |5 is paid, making $10 for the complete
service.
She next is seen by the doctor in charge of the clinic, who
is a man of broad obstetric training. He takes her medical
and previous obstetric history, examines her, including the
chest, pelvis, urine, blood pressure, and predicts the probable
outcome. She is then given prenatal advice and instruction,
with instructions to return one month before the expected
date, for re-examination.
Her name is given to the prenatal nurse, who visits her in
her home, at intervals not over ten days. This nurse is
especially trained in prenatal work and examines the urine
and blood pressure, as well as observing her general health
and surroundings. The nurse's records of visits are entered
immediately at the clinic. She instructs the district nurses
in prenatal care.
The name, address and points of medical interest in the
case are mailed to the doctor who is to deliver her. The pre-
natal nurse also reports to him anything abnormal and if nec-
essary, he visits the patient and treats her, carrying the re-
sponsibility of the case, consulting the physician in charge
when he desires.
At present there are two physicians on duty, both grad-
uates of the Boston Lying-in Hospital. They deliver the
cases, when called by telephone, and make what they consider
the necessary number of postnatal visits, usually three to five.
For this service they receive $5 a case, and are paid by the
dispensary, turning in all money collected by them.
227
228 OBSTETRIC CARE
The puerperium or postnatal period is also covered in the
usual way, by the district nurse. Some day we hope she may
be the same individual as the prenatal nurse. We hope still
further that we may soon have a nurse present at the delivery
to assist the doctor. On account of the great irregularity of
the time needed this is always a hard problem to solve. But
as the clinic grows we hope to work it out satisfactorily.
To summarize : The case is booked by a paid social worker ;
examined, pays $5 at the first visit. A prenatal nurse visits
her every ten days till delivery. She is delivered by a doctor
especially trained in obstetrics, paying him a second |5. She
is visited by the doctor and a district nurse for ten days fol-
lowing confinement.
The dispensary pays the doctor $5 for every case. If the
case pays the full fee the dispensary pays the Instructive Dis-
tricting Nursing Association $2, and retains the other $3.
Since February 1st, when the obstetric clinic was started
18 cases have been cared for up to October 15th, with no
maternal death and one foetal death on the 9th day from
"convulsions."
One hundred and thirty dollars have been received, an
average of $7.22 per patient.
I am informed by the doctor that from his point of view,
the arrangement is very satisfactory. He is guaranteed $5
for each case. We have to thank the Nursing Association for
excellent nurses. Our social worker is a distinct help espe-
cially on the financial end of which she has charge.
In conclusion, I must say that with so few cases and in such
a short time, no general statements seem justified, but we feel
confident that the experiment is going to be successful.
The scheme is simple, an organization of the forces available,
in most communities, independent of medical schools. There
must also be added to this scheme a few available surgical
beds in a good hospital where the major operative work can
be properly handled.
We realize that the personal skill, enthusiasm, and conscien-
tiousness of the social workers, nurses, doctors and even trus-
tees, is what makes success; that no system can supplant or
succeed without these personal human qualities.
It is our hope, however, that even when the glamor of new-
ness has worn off that there may still be left the foundation of
a system insuring good, safe, obstetric care to the immigrant
class of our population.
REPORT ON THE WORK OF THE MASSACHUSETTS COMMISSION
FOR THE BLIND FOR PREVENTION OF BLINDNESS FROM!
OPHTHALMIA NEONATORTJM
DURING THE TBAE BEGINNING NOVEMBER 1, 1912
HENRY COPLEY GREENE, Field Agent for Conservation of Eyesight
A Member of the New England Snto-Committee
In answer to the chairman's questions in regard to ophthal-
mia neonatorum the following is submitted :
The work of the Commission for the Blind against ophthal-
mia neonatorum may be divided into educational work, legis-
lative work and the enforcement of existing law.
The commission's educational output with regard to oph-
thalmia neonatorum included a traveling exhibit, pamphlets
and leaflets, and speeches and personal interviews by the
agent for the Conservation of Eyesight. The exhibit, origin-
ally prepared for the Congress on Hygiene and Demography,
shows not only the prevalence of various causes of blindness
but various medical and social efforts for their eradication.
This exhibit forms a part of the traveling health exhibition
which the State Board of Health is showing in the public
libraries of various cities. The commission's new leaflets in-
clude one prepared for the New Hampshire Health Day and
since widely distributed in Massachusetts, and a leaflet on
infant hygiene prepared in conjunction with the Milk and
Baby Hygiene Association and printed by the State Board of
Health. This infant hygiene leaflet, which contains a warn-
ing against ophthalmia neonatorum, is intended for distribu-
tion to the mothers of new-born babies, as soon as each birth
is registered; and we are informed that the State district
health inspectors are urging its use in the different cities and
towns.
The more personal work of education has consisted in in-
terviews with, various physicians involved in ophthalmia cases
and in addresses for example to the Berkshire County Asso-
ciation of Boards of Health, to a nurses' club in Worcester
and to the local medical society at Haverhill. This last ad-
dress, which is an attempt to set up definite standards of
treatment for ophthalmia neonatorum, has been distributed
by the State Board of Health to all local boards.
In the course of its legislative work the commission helped
kill the bill in the last legislature which provided for the
registration of midwives without examination. It framed and
229
230 HENRY COPLEY GREENE
helped to pass a bill empowering the State Board of Health
to require the reporting of diseases in any way that it sees
fit and providing a penalty for failure to report as directed.
This law makes it possible for the State Board to require the
reporting of gonorrhea and syphilis by hospitals and institu-
tions without requiring the reporting of these diseases by phy -
sicians. It also makes possible the reporting of these diseases
by office number, as in California, instead of with the name
and address of each case. The commission also helped to
draft and pass two eugenic bills, one providing that appli-
cants for a marriage license be furnished with a list of legal
impediments to marriage and required to take oath as to
whether they suffer from such impediments; the other provid-
ing for an investigation of impediments to marriage by the
joint boards of health and insanity. If these enactments are
properly supported by such societies as the Association for
the Study and Prevention of Infant Mortality, they should
ultimately result in more accurate knowledge as to the pre-
valence of gonorrhea and more adequate provisions for its
treatment. This legislation should also result in an authori-
tative statement by the State Boards of Health and Insanity
as to what diseases should be seriously considered by appli-
cants for a marriage license, and by further legislation re-
quiring applicants for a marriage license to take oath as to
their physical condition.
In its work for the utilization of existing law the commis-
sion has successfully urged the distribution of the State
Board of Health's nitrate of silver droppers to rnidwives as
well as to physicians. The commission has also seconded the
work of the State Board of Health and the State Board of
Charity in connection with lying-in hospitals. A construc-
tion of the reporting law by the attorney-general has been se-
cured, making it clear that ophthalmia neonatorum must be
reported whenever it is observed and not merely within the
first two weeks; and information has been furnished, both to
the Boston Board of Health and to the Society for the Pre-
vention of Cruelty to Children, which has resulted in prose-
cutions by both of these bodies.
The culprits in a few typical cases are as follows :
1. A physician at St. Mary's Infant Asylum, whose failure
to report a case of ophthalmia neonatorum at that institution
made it impossible for the Boston Board of Health to super-
vise the treatment and prevent the child's blindness.
NEW ENGLAND 231
2. A member of the Massachusetts Medical Society prose-
cuted by the Boston Board of Health and fined $50.
3. A midwife prosecuted by the Boston Board of Health
and though the baby in her care became totally blind, fined
only $10.
4. A French physician in Holyoke successfully prosecuted
by the S. P. C. C. '
In the four instances just mentioned only two of the babies
became blind. During the last year, however, four cases of
practical blindness in both eyes, resulting from ophthalmia
neonatorum and neglect, have been brought to the attention
of the Commission for the Blind. In other words, 2 per cent
of our new cases of blindness are still due to ophthalmia
neonatorum. This per cent is the same as that for the year
ending January 1, 1913, a percentage verified by a state-wide
inquiry among lying-in (hospitals, oculists and physicians.
While this percentage is much lower than it has been in the
past it should be still further reduced. If it is to be further
reduced it must be done by lines of work in which the Associa-
tion for the Study and Prevention of Infant Mortality is
actively interested. Such leaflets on the general subject of
infant hygiene, including ophthalmia neonatorum, as that
published by the State Board of Health, should be universally
distributed ; the average of obstetric service should be raised ;
and the present sporadic prenatal and infant hygiene work
should be extended, and unremittingly carried on throughout
the state by social minded physicians and nurses.
SUPPLEMENTAL, REPORTS Continued
FALL RIVER
The Civic Department of the Woman's Club of Fall River
furnished a fund to enable the District Nursing Association
of Fall River to investigate the vital statistics of children born
in the city during the months of June, July and August and
for a period of three months from each birth. The histories
of the children born during the month of June are the only
ones now available, as three months have not yet elapsed since
the birth of children born during the latter months.
232 REPORT
The population of the city is approximately 120,000; and
the parentage is a follows :
Parents and grandparents born in the United States, i. e
American extraction 19
English
Irish
Italian
Fr.-Canadian
Portuguese
Syrian
Jewish
Slavic
Mixed
24
11
8
86
68
3
3
38
38
298
Histories uncompleted 3
301
Of the above births, 196, or 65 per cent were attended by
physicians; 99, or 33 per cent, by midwives; and 6, or 2 per
cent, with no attendance.
The total infant deaths during three months were 42. Of
these, 33, or 78.5 per cent, were of children attended by phy-
sicians at birth ; 8, or 19 per cent, were of children attended
by midwives ; and 1, or 2 per cent, were unattended.
Of the births attended by physicians, 16.8 per cent died;
attended by midwives, 8 per cent died; and of those unat-
tended, 16 per cent died.
Of the above number, 4, or 1.3 per cent, were still born.
This figure is apparently abnormally low and investigation
for a longer period would probably indicate a larger per-
centage of stillbirths. Moreover, some births listed herein as
premature would be reported as stillborn.
Of the total number of births, 1.6 per cent were premature,
resulting immediately in death, and death resulted imme-
diately from other causes in an additional 1.6 per cent of the
total number of births; making the total number of deaths
attending birth, including still born, 14, or 4.6 per cent, while
the total percentage of deaths to births was 10.6 per cent.
Deaths may be attributed as follows :
18 to Prenatal causes :
Stillborn, 4
Premature, 11
Bright's disease, 1
Syphilis, 1
Exhaustion, 1
14 to Prenatal causes or improper attendance at birth:
NEW ENGLAND 233
4 to neglect or improper care after birth :
Improper food
Condensed milk
Condensed milk and neglect
Drunken mother, filthy home, cruelty, neglect
4 to after acquired diseases:
Whooping cough
Cholera infantum
2 to causes not assigned :
Convulsions
Malnutrition
The record form used was published by the Eussell Sage
Foundation.
As soon as the birth reports were received by the Board of
Health, copies were forwarded to the District Nursing Asso-
ciation, and a nurse assigned to look up all births in her dis-
trict. Thereafter the child was observed until death or the
termination of the three months period from birth. Because
of errors in registration, due to ignorance of foreign names,
or carelessness, it sometimes became difficult to locate the
family and to correlate a birth with a death; but by figuring
the period of life as stated in the death certificate a reason-
able degree of identity was secured. This difficulty indicates,
however, that vital statistics, as now recorded, are apt to
proye misleading unless carefully verified, especially after a
lapse of years. Practically every child born during the month
of June has been traced to death or the full period of three
months, except three who removed from town, and, so far as
can be learned, these were in good condition upon removal.
It is not pretended that the experience of one month fur-
nishes a sufficient field for accurate data, the present report
being offered as the only one available at the present date.
The preliminary report submitted herewith was compiled from
the records by Miss Alice Brayton, a volunteer worker.
MIDWIVES IN NEW ENGLAND
MAINE
Dr. H. J. Everett of Portland, Maine, reports the midwife
situation has shown no change in the last year. As far as
can be ascertained the midwife does not exist in Maine except
in isolated instances, and it can be stated with comparative
certainty that less than 0.5 per cent of all the births in the
State are cared for by midwives.
234 REPORT
As to the standing of obstetrics in the State, practically all
the physicians, with the exception of the oculists and those
limiting their practice to diseases of the ear, nose and throat,
are practising obstetrics. In Portland there are some half
dozen trained obstetricians, but even among these the recogni-
tion for services rendered is less than for similar surgical
attendance.
VERMONT
In spite of repeated attempts, we have been unable to meet
with any cooperation from the medical profession in Vermont
this year, but we have every reason to believe that the mid-
wife is as she was a few years ago, practically non-existent
in the Green Mountain State.
NEW HAMPSHIRE
Manchester
Manchester is a mill and manufacturing city, with textile
mills and shoe factories as its principal industries, the two
largest corporations alone employing 23,000 operatives, a large
proportion of this population being foreign-born, or of foreign
extraction. Out of the total population of 75,000, census of
1910, there are, approximately, 25,000 French Canadians,
10,000 Greeks, 5,000 Germans, Poles and other foreigners well
toward 5,000.
The total number of births for the year 1912 was 2,149, of
this number 94 were delivered by midwife, of which there are
in the entire city, 6. Of these 6 midwives, 2 delivered 1 case
each, 1 delivered only 5, and the remaining 3 delivered 11, 28,
48, respectively.
The remaining cases that would naturally go to midwives
were cared for by the District "Nursing Association, totaling
144 babies.
So effective has been the work of this association that dur-
ing the past year the midwife with the largest number of
eases credited to her name has decided to move to more lucra-
tive fields.
It is readily seen that the Nursing Association has cared for
61 per cent of the cases that would otherwise have fallen into
the hands of midwives. To state the facts in a different man-
ner, the deliveries by midwives have been reduced from 100
per cent to 39 per cent by the work of the association. The
total deliveries by all midwi-ves and the association together
being considered as 100 per cent.
NEW ENGLAND 235
Of the total births In the city for the year 1912, which were
unable to afford either the services of a private physician or
pay for hospital accommodation., 4.3 per cent were delivered
by midwives, and 6.6 per cent by the Nursing Association.
The department of the District Nursing Association in
charge of the obstetrical work, has a physician as its executive
head. The medical services of the association are free, the
patients being required to pay what they are able towards the
other expenses (nurse, supplies, etc.)
This free work is divided among the younger doctors in the
city, each serving two or three months gratis during the year,
at the call of the association. None of these are at present
graduates of an obstetrical hospital, but they are all fresh
from their general hospital work. There is but one graduate
from an obstetrical hospital in the city. Neither he, nor any
other physician in the city, is limiting his practice exclusively
to obstetrics or obstetrics and gynecology combined.
The compensation for obstetrical service is much below that
paid for surgical work requiring the same degree of knowl-
edge, skill and attention.
MASSACHUSETTS
Boston
To throw light on the activity of the midwife in Boston
your committee through the assistance of the Board of Health
Nurses had a card catalogue of all the midwives engaged in
practice. There has only been one addition to the list pub-
lished last year. At the present time there are thirty-five known
midwives practicing in the city. None of these report births,
the certificates all being signed by physicians, some of whom
make one visit on the case either during labor or on the first
day after delivery. In the heart of the Italian section where
there is the greatest activity on the part of the midwife these
figures were collected from the records of one of the stations
of the Baby and Milk Hygiene by Miss Gallagher. Of the
284 cases applying to the station for advice from October 1st,
1912, until October, 1913 :
Midwives attended 119 at birth
Private physicians 65
The Boston Lying-in Hospital 63
Doctors and midwives 20
Hull Street Dispensary 14
St. Elizabeth's Hospital 2
New England Hospital 1
284
236 REPORT
From this we can safely judge that in this small region of
the greatest midwife activity in the whole of Boston (18 of
the 35 known midwives lived within a radius of a quarter of
a mile of this milk station), less than 50 per cent of the cases
are delivered by midwives.
FAIX RIVER
In Fall Eiver from a member of the Board of Health we
learn that there are twenty-three midwives in that city, most
of them in active practice and reporting about one-third of all
the births. A daily list of reported births is forwarded to
the Board of Health Nurse, and the District Nursing Associa-
tion so that all births among the poorer classes are quite
promptly investigated by a nurse. All midwives are listed
by the Board of Health as soon as they appear. These women
are carefully followed up as to the use of the ophthalmia
prophylactic and instructed in the use of this by the Board
of Health Nurse. Until the midwife shows that she is com-
petent to use it she is not equipped with an outfit. There is
at present no substitute agency which provides obstetrical
service in Fall Eiver, and little prospect of one in the im-
mediate future, because of the hostility from a part of the
medical profession. The report from the Civic Department
of the Women's Club of Fall Eiver (page 231) shows the
quality of obstetrical attendance the physicians and midwives
are furnishing.
RHODE ISLAND
Providence
Dr. Ellen A. Stone of Providence, reports as follows: The
midwifery conditions of Ehode Island have not materially
changed since they were presented in tabulated form to this
committee at the Chicago meeting of the American Associa-
tion for Study and Prevention of Infant Mortality in 1911.
The midwife is not recognized by the Medical Practice Act
of Ehode Island yet certain duties are prescribed for her;
among them being the reporting of births and reporting of
inflamed eyes.
Certain midwives in Providence deliver only a few cases
each year, while others are extremely active. Three midwives
each delivered over 150 babies in 1912. The midwives in Provi-
dence report births very promptly to the City Eegistrar on
GEORGE W. KOSMAK, M. D. 237
postals provided them by the Health Department. In 1911
33 midwives reported 1,637 births; in 1912 39 midwives re-
ported 1,694 births.
Since March, 1911, a nurse has heen employed by the Super-
intendent of Health of Providence to visit all infants delivered
by midwives and instruct the mother in regard to feeding and
caring for her infant. This nurse visits the baby on the third
or fourth day after birth and again when it is from eight to
fifteen days old. More visits are made if there is need.
During 1912 the nurse visited 1,691 babies making in all 3,421
visits.
The nurse also has instructed the midwives in the manage-
ment of their cases and has insisted on their being more
cleanly, so that there is considerable improvement of condi-
tion among the midwives in Providence over that reported at
the Chicago meeting in 1911.
CONNECTICUT
New Haven
The midwives are very active in New Haven and all classes
of these women exist. Several unlicensed women have friends
in the medical profession who sign the birth certificates.
Other older women who were admitted to practice at the time
the registration law was passed are doing very poor work.
Some of the women who have been examined and licensed are
doing fairly good work and all of this last class seem to be
doing better work than the midwives in the other two classes.
REPORT OF SUB-COMMITTEE FOR NEW YORK AND NEW JERSEY
GEORGE W. KOSMAK, M. D., New York:, Chairman
NEW YORK
By way of preface, the scope of this committee's work may
be stated briefly to be as follows: On account of the large
extent of territory covered a small centralized committee
would not be able to study the question owing to the time re-
quired and the expense. It was thought best therefore to ap-
point one or two members of this committee in each city or
town who, being familiar with the local conditions, would be
better able to make an intelligent study and a comprehensive
report. This, however, was the first stumbling block in the
work, for it was only by personal recommendations that the
238 REPORT
names could be secured of those who might take an interest
in this work. A considerable number of physicians and others
were communicated with by letter but the responses were not
particularly satisfactory. Those however, who agreed to join,
may be complimented on the energy with which they have
attacked their task and rendered a report within a short time.
In selecting the investigators in each locality, the endeavor
was also made to secure persons who would consider the
obstetrical phases of the midwife practice as well as the social
side. It is unfortunate that in similar investigations made
in the past, the work was often done by individuals who
were not familiar with this phase of the situation or who did
not take an interest in the same, who were more concerned
in the feeding, clothing, etc., of the infants, than the possible
effect of improper obstetrical care on the mothers.
The comparatively brief space of time since beginning the
work has made it impossible for me to extend the same as
widely as desired, but if a continuation of the work of this
committee is agreed upon, further steps will be taken to secure
a more wide-spread representation of the same. This more-
over, leads me to suggest that committees of this kind be made
permanent and that the presentation of a formal report be
not the end of their labors. It is very essential that the agita-
tion for better obstetrical care for women in the poorer walks
of life, be made a continuous feature of the work of this
society, for an important point in providing for the welfare
of infants, is to provide for healthy mothers. It is not only
necessary to study the midwife but also the obstetrical prac-
tice of the local physicians and maternity institutions. This
feature, however, will be a matter for future consideration.
It is next in order to consider the reports of those investi-
gators who have thus far consented to aid in this work, and
I take great pleasure in submitting the same in their entirety :
tltica
Dr. T. W. Clarke of Utica, is the Medical Director of the
Public Welfare Committee of that city and sent out a circular
letter to each practicing midwife requesting information as
to her methods of work, etc. In connection with his inquiries,
he found that the only law affecting midwives is one in
reference to the requirements of letters of recommendation
from two physicians and registration at the office of the Board
of Health. There is absolutely no restriction or oversight of
any kind. Sixteen midwives are registered in Utica, of whom
GEOEGE W. KOSMAK, M. D. 230
two have practically retired, three are but recently registered,
and eleven are in more or less active practice. Of the latter,
six are Italians, three Polish, one Jewess, and one English.
The largest number of babies delivered in 1912 by one midwife
was 139. Two others delivered 132 and 129 each. The smallest
number was 6. Of 2,131 births recorded by the Board of
Health in 1912, 775 were attended by midwives. There being
no inspection, the quality varies greatly. The one Jewish
midwife is reported to be clean, careful, and a good diagnosti-
cian, and prompt to call medical aid when required. Most
of the Italian women have diplomas from Italian institutions.
That the Polish are pretty poor, is shown by the fact that one
physician stated that he had treated three bad cases of sepsis
within a few weeks, in the practice of one midwife who had
the largest number of cases in the city. In reply to questions,
the midwives stated that they used antiseptics for both their
hands and the mothers, and silver solution in the babies'
eyes. Dr. Clarke is inclined to doubt the veracity of these
statements and feels that some more rigid method of qualifi-
cation and regular inspection is greatly needed in Utica.
New York: City
Dr. S. Josephine Baker, Director of Child Hygiene of the
New Tork Department of Health, has recently published a
very excellent report on the subject of midwives, included in
a monograph issued by the Department in August, 1913. She
states that 40 per cent of all the births in the city reported
in 1912, were attended by midwives, or out of a total number
of 135,655, 52,743 were under their care. A very extensive
investigation has been made by the authorities of the City of
New York on the question of licensing midwives, and strin-
gent laws for their government have been formulated. A
special staff of five medical inspectors and nine nurses is
assigned to this supervision, the details of which are too ex-
tended for presentation in this connection.
Dr. Baker is convinced that the standard in New York
City has improved since the organization of the various
methods of inspection by her department and it is not my
purpose to discuss the question at this point. Attention may
be also called to the fact that a school for midwives under the
control of Bellevue Hospital, has been established in which a
course of instruction, both practical and theoretical is given.
It is apparently the only one in existence in this country
which maintains a reputable standard.
240 REPORT
Syracuse
Dr. P. S. Potter, Syracuse, N. Y., submits the following
brief report as regards midwifery conditions in Syracuse :
"A new law goes into effect on January 1st, requiring ex-
amination for tlie licensing of midwives, after which more
complete statistics will be available. As yet there are no
specific regulations covering the practice of midwives in Syra-
cuse. The city has twelve midwives who file about six hundred
out of three thousand births a year. The majority are Poles
and Italians. One is a German who has a foreign diploma,
and another midwife has a New York City license. The
statistical clerk stated that there was an indiscriminate prac-
tice of midwifery and there were some of these women who
did not file birth certificates. The only complaint against
midwives in this particular city was, that medicines had been
occasionally administered. Instances were known however,
where midwives did, or tried to do a version or remove ad-
herent placentae. It is stated that the number of midwives
in Syracuse is increasing because of the lack of restrictions."
The subject has received new interest by the local profession
as is evident from recent reports in the daily press of an
agitation to limit and control the practice of midwives after
an exposure of certain of their cases. It would be a matter
for congratulation if this reform is consistently followed up
in Syracuse.
Schenectady
Dr. Frank Van Der JBogert of Schenectady, N. Y., under
date of October 25, 1913, submits the following facts from
the records of the local health department :
Number of births registered during 1912 1977
Number of births attended by midwives 665
Number of midwives attending (names taken from records of
first six months 1912) 13
Licensed physicians in city, about 100
Number of stillbirths attended by midwives 11
Number of stillbirths attended by physicians. 43
Coroner's case 1
Of 83 deaths in 1912 of infants under two weeks old, the births
were attended by midwives in 12
The births attended by physicians in 58
Attendants not found in 13
Prematurity was given as the cause of death in 42
In one instance he found a record of the death of mother
and child due to inability of midwife to deliver aftercoming
GBOEGB W. KOSMAK, M. D. 241
head. ^ This was the only instance in which the ability of the
midwife was questioned and there were several cases recorded
as attended by physicians where the causes of death were
given as due to difficult labor or birth injury. Dr. Van Der
Bogert states :
^ "My investigation up to the present time, leads me to be-
lieve that either the midwives of this city are doing fairly
good work or that they call physicians to their aid when in
trouble.
"The Health Department here has no supervision over mid-
wives though they are asked to register their names and
addresses.
"There is no doubt as to the capability of our regular licensed
physicians taking care of all cases, since we have one hun-
dred physicians in the city, most of whom do confinement
work and the average birth rate is 2,000 annually."
The last paragraph contains an admission which it would
be wise to consider by those who claim that the midwife must
exist in local communities, because there are not enough phy-
sicians to do the work.
Rochester
Dr. G. W. Goler, Health Officer of the City of Rochester,
N. Y., under date of October 30th, writes as follows :
"Rochester operates under a law passed in 1895, entitled
'An Act Regulating and Restraining the Practice of Mid-
wifery in the City of Rochester.' It has a board of three mid-
wifery examiners, including the health officer, who is a member
ex-officio. I have made no stated report upon the midwifery
condition in Rochester, but from time to time I have made
statements in the annual reports relating to the practice of
midwifery."
"We have but seven legally qualified midwives in Rochester,
and we have gradually reduced the number of births attended
by midwives from over one-third of all the births, to about
one-fifth. We are unable to deal with the problem of the
midwife who practices illegally. We get these people into
the police court only to have the police judge discharge them.
We have never been able to punish a midwife for illegally
practicing midwifery."
242 REPORT
NEW JERSEY
Patterson
Dr. C. J. Kane of Patterson, N. J., bases Ms report on facts
procured from the City and State Boards of Health, from the
County Clerk's office and from several of the midwives them-
selves. The number of midwives registered in Passaic County
since 1896, is twenty-four in Patterson alone. The number
of births in 1912 in Patterson was 2,519, of which 840 were
attended by midwives, about one-third of the total number.
Registration is only allowable after examination at the State
Capitol. Dr. Kane states that the midwives in Patterson
send for medical aid when required and many of the compli-
cated cases are sent to a hospital. It will be observed that
the proportion of births of this city is considerably less than
in the neighboring city of Newark.
Orange
Dr. Katherine Porter of Orange, N. J., presents the follow-
ing very complete and satisfactory report :
u The four Oranges, comprising Orange, East Orange, West
Orange and South Orange, have a total population of about
90,000 and belong to the semirural type of community. Orange
and East Orange are cities, South Orange is a village, and
West Orange is a township."
"There is a large Italian and negro population with some
Russians, Germans, etc. It is among the former that the four
midwives ply their trade. Two of the midwives are Italians,
one is German and one is a negress. Their ages vary between
37 and 70 years. Three claim to have diplomas from institu-
tions where they attended lectures from six months to three
years. Two of these were trained in Europe, one in New York
City. The negress has had no special training, is 70 years old,
incompetent and dirty. All have received their licenses from
the County Clerk in Newark, but afterwards there is no super-
vision of any kind over them by the municipality in which
they practice. During 1912, the four midwives reported 389
births and about 150 physicians reported 1,158 births, the
midwives thus doing one-third of the obstetrical work.
"In Orange where there are many Italians, the physicians
reported 492 births, the midwives 307 births,
"In Orange the nationality of the mothers attended by mid-
wives during 1912 is as follows :
Italy, 244 ; Austria, 3 ; Roumania, 2 ; Hungary, 1 ; United States, 39 ;
Scotland, 1 ; Greece, 2 ; Russia, 5 ; Colored, 13 ; Ireland, 3 ; Germany, 2.
GEORGE W. KOSHAK, M. D. 24B
ntidwives are supposed to call in a physician if any
abnormality occurs and in many cases I think this is done,
sometimes possibly too late. The Board of Health is very
strict about enforcing the law of reporting sore eyes among
babies, and I think the midwives are thoroughly alive to the
seriousness of any disobedience of this law.
"We have in the Oranges a splendid work which acts some-
what as a check on the midwives, that of a nurse who is sup-
ported by the Committee for Prevention of Infant Mortality,
and who acts as a special inspector of the Board of Health
under the supervision of the committee and the health officer.
Her work consists in visiting the homes as soon as practicable
after a birth has taken place, to give instruction to the mother
in the care of the child. The home care and the modification
of milk is also taught. With a few exceptions, only those
cases in which the child was delivered by a midwife were
taken, in other words, those having the least favorable environ-
ment and most in need of attention. Altogether during 1912,
3,095 instruction visits were made by the nurse.
"The records as they are now kept in the various Boards of
Health, do not show whether death of a mother or a child,
is the result of carelessness of the midwife or not, as phy-
sicians must sign death certificates and send in notices of
stillbirths. The part the midwife plays can only be ascer-
tained by further investigation. This was done in Orange
with the following results: During 1912, 28 children under
10 days died, six of these were midwife cases, 22 were deliv-
ered by physicians. The deaths of five mothers were reported,
one was attended by a midwife, cause of death 'retained
placenta' four were attended by physicians. The hospital
records also do not help very much in determining whether a
midwife was responsible or not for a case of puerperal sepsis,
as little attention is given to that particular phase of the
question. On the history there may, or may not be any men-
tion of it.
"In summing up the situation in the Oranges, I would say
that the condition though bad enough, is not so serious as in
the large cities. The communities are small enough to act as
self-imposed inspectors, and very little occurs that is not
known. The negro midwife is old, dirty and untrained and
should not have her license. The other three are comparatively
intelligent. The homes of two are very neat and clean, the
other, an Italian, is very dirty. The nurse inspector who
244 EBPOBT
visits the homes of the mothers within five days after the birth
of the child, acts as a wholesome restraint on the midwife and
is responsible for the better conditions that exist."
Newark:
Dr. Julius Levy, Director of the Department of Child
Hygiene of Newark, N. J., presented a very extensive report
of the conditions in his city as these had already been worked
out. This report may be summarized as follows :
Of 114 midwives, forty have certificates from various
American schools for nurses or midwives, although he believes
that many of these certificates do not represent real schooling.
Fifty-three midwives have licenses issued by the New Jersey
State Board of Medical Examiners. The latter are stated to
be very superficial in character. Twenty-one midwives have
foreign diplomas. A study of his personal records shows, that
one midwife delivered as many as forty cases in one month
and had an average for six months of thirty-three. There has
recently been established in Newark, a maternity hospital and
school for midwives, in which it is intended to give a two
years' course of seven months each. The Visiting Nurses
Association is attempting to meet the midwifery question by
offering to supply a physician to women for the sum of $5.00
and then have the case followed up by a visiting nurse.
Although this has been done in a few cases and proven satis-
factory, Dr. Levy does not consider that it will make any
great in-road on midwifery practice. He finds moreover, that
midwives are accustomed to advertise in the local newspapers
and he has the record of a case where a midwife was indicted
for malpractice but not convicted and her advertisement con-
tinues to run in one of the most popular papers. Dr. Levy
conducted last year, a course of lectures for midwives, prin-
cipally on infant hygiene, the importance of maternal nursing,
and the care of the infant in the first week or two. He be-
lieves that much can be accomplished along these lines.
An interesting feature in connection with Dr. Levy's report,
are extracts from the report of the Public Welfare Commis-
sion of Essex County for 1912, on the subject of "Infant Mor-
tality." In children under two years of age which were
brought to the Consultation Station, the highest mortality
was found among Italians where the mothers were almost ail
confined by midwives. There were a total of 135 midwives
in Newark, practicing in November, 1912, whose proportion
of deliveries was 52 per cent Dr. Levy believes that the mid-
GEORGE W. KOSMAK, M. D. 245
wife exerts an important influence in the early life of infancy
and should for this reason be carefully* supervised by the
authorities.
In addition to the cities mentioned in the preceding portion
of this report, I also communicated with physicians in other
cities in reference to the study of the midwife situation in
their respective communities. From some I was unable to
obtain any assistance and in other cases, the time has been too
short to obtain a suitable report. By way of comment on the
preceding statements, attention may be called to the following
fajcts: The communities referred to may be accepted as
typical of what probably obtains throughout the two states
under consideration, and shows conclusively the lack of suffi-
cient information on this important subject. We find for ex-
ample, that in most localities, the midwives practice without
supervision, or supervision that is more or less superficial in
character. The practice of these women seems to be largely
among the foreign population which we may assume to be
ignorant in most instances of our national customs. It ap-
pears moreover, that particularly in the smaller cities, the
practice of the midwife as regards the proportion of births
attended, is not as great as in the larger cities. Any extended
investigation of the subject must depend largely on the in-
stigation of local measures which may be best adapted to
each particular community. A suggestion might be made in
this connection that committees of physicians and prominent
lay persons in each city or town could take up this question
as a unit; all this being done under the guidance of a central
committee sufficiently large to include one member in each
city of each state. If these local committees work as units
under the suggestion and advice of a central committee, a
great deal of time and expense would be saved and greater
local interest generated. The notion of home rule should
apply primarily in investigations of this kind and every com-
munity should be its own mentor. The experiences of each
however should be published and circulated so as to be of ad-
vantage to their neighbors.
In conclusion the writer ventures the hope that the work of
the present committee be continued, that further efforts be
made to obtain information about the midwife from centers
not thus far heard from, so that the continued progress in
this important work may be reported at the next annual
meeting of our Association.
REPORT OF SUB- COMMITTEE FOR THE SOUTHEASTERN STATES
AND THE DISTRICT OF COLUMBIA
JOHN L. NORRIS, M. D., Chairman, Washington
Anyone who has made a study of mortality statistics by age
periods is aware that the highest rate is for the first year, and
that the rate for this year exceeds, as a rule, that of any later
five-year period. Of those dying during the first year, ap-
proximately 30 per cent, or almost one-third, succumb during
the first week. In cases where midwives are employed the
time for which they are expected to be in attendance is during
the confinement and for a week or ten days succeeding. It
should not be inferred that the midwife is responsible for the
high mortality of the first week, but it is true that her services
cover that period during which the infant's life is in greatest
jeopardy and at the time when the greatest care should be
exercised.
Under the most competent care, the mortality during this
period would be high, since prenatal conditions are largely
responsible. These prenatal causes of deaths of infants can,
to a great extent, be avoided by proper care of women during
pregnancy. When physicians are engaged they do advise the
necessary care and treatment of the expectant mother, but
this is more than can be reasonably expected of the average
midwife.
In the southeastern section of our country midwives belong
usually to the colored race, although one member of our com-
mittee reports that in one locality old men, incapable of doing
other work, follow this calling. As the tasks of the midwife
are extremely unpleasant and as the amount of money col-
lected for their services is very small, only those of this race
who are either physically or mentally unfitted for other work,
follow this business. There is no question but that the legis-
lators realize these conditions and the resultant danger both
to the mothers and infants, but they also realize that to for-
bid the practice of midwifery by these women, would in many
instances result in there being no attendant whatever upon
cases of confinement. Neither the States of Virginia, West
Virginia nor North Carolina require that persons engaged in
the practice of midwifery secure a license. The midwife
passes no examination to show her fitness to follow this grave
calling. She need not be able to either read or write. In fact,
there is no restriction whatsoever, except in a few cities of
Virginia, where midwives are required to register. In the
District of Columbia before engaging in the practice of mid-
246
JOHN L. NORRIS, M. D. 247
wifery, a person must secure a license and before such licenses
can be granted the applicant must pass an examination be-
fore a board of duly appointed physicians, which will demon-
starte that they are qualified to perform the duties of a mid-
wife. This law, which was approved June 3, 1896, allowed
those midwifes in practice at that time to secure a license
without examination. The most of those who were thus
exempted from examination were of the "old mammy" type
ignorant, superstitious, dirty. That they had borne children
or been in attendance at the time of a birth, they deemed suf-
ficient to qualify them as accouchers. Fortunately, most of
them were aged women and their practice confined to but a
few years. Of the 130 licensed in!896, scarcely 20 are alive
and in practice at the present time. The mid wives who have
been licensed since 1896 are of a much higher type. Some of
them have been trained in European schools of midwifery and,
though not competent to cope with the more difficult labors,
their knowledge causes them to realize the dangers and to
summon proper assistance. Others are trained nurses and
at least one is a graduate of a medical school who failed to
secure a license to practice medicine. (It might be mentioned
here that while this woman cannot lawfully prescribe a dose
of quinine for a chill, she can lawfully undertake the most
difficult labors.)
The members of this committee from North Carolina report
that about fifty per cent of the midwives in that state are
unable to either read or write. The same holds true of Vir-
ginia. No data are available from the State of West Virginia,
but as no license is required, the percentage of those who can
neither read nor write is probably about the same is in the
other Southeastern States. The illiterate midwives in the Dis-
trict of Columbia are, of course, confined to those in prac-
tice at the time of the passage of the law. As stated above,
about 20 are still in practice. One would suppose that where
midwives are employed, it would be by those persons whose
finances were such that they were unable to secure the serv-
ices of a physician. This is, as a rule, true, but in North
Carolina, Virginia, and in the District of Columbia, midwives
are employed, to some extent, by persons financially able to
pay a physician. In some instances a feeling of modesty may
be responsible for the employment of women. But now that
women are so largely entering the field of medicine, the time
will soon come when in all the States the services of competent
practitioners who are women will be obtainable.
248 REPORT
There can be no doubt that the public is being gradually
educated to the dangers of employing unskilled attendants in
cases of confinement. The latest data which can be secured
for the District of Columbia show that midwives are in at-
tendance at about 13 per cent of the births, while in 1896, 48
per cent of births were attended by midwives.
None of the States represented by this committee employ
physicians or trained nurses whose duty it is to visit such
cases as are attended by midwives to see that the mother and
child receive proper treatment. This is also true of the Dis-
trict of Columbia. Though, fortunately for the District of
Columbia, a philanthropic society known as Instructive Visit-
ing Nurses 7 Society, has, voluntarily and without remunera-
tion from the government, been for years employing nurses to
visit all cases of confinement where midwives are in attend-
ance. Their object is to see that the mother is properly in-
structed in the care of the child and that both mother and
child receive proper attention. The Health Department im-
mediately upon the receipt of the return of birth by mid-
wives notifies them. Work of similar character is conducted
in the larger cities of Virginia and I have no doubt the same
is true in other Southeastern States.
In the States of Virginia, West Virginia and in the Dis-
trict of Columbia midwives are required to make returns to
either municipal or State authorities of all births attended by
them. While many of the cities of North Carolina have local
ordinances requiring the reporting of births by midwives these
reports are not demanded in all parts of the State.
In none of the States represented by this committee nor in
the District of Columbia is there a law requiring prophy-
lactic treatment of the eyes of those infants attended by
midwives. In Charlottesville, Va., the local health officer has
instructed the midwives in the care of the eyes of infants and
is following the cases attended by them with a view to pre-
venting infant blindness. In the District of Columbia, though
the law does not require that the midwife administer prophy-
lactic treatment, it does require that midwives report to 1he
health office within six .hours of the time it is noticed, any
inflammation of the eyes of a new-born infant attended by
discharge of pus. All midwives practicing in the District of
Columbia are supplied free of charge with sophol. This medi-
cine can be administered with safety and has proved to be as
efficacious in preventing gonorrheal opthalmia as the nitrate
of silver, the use of which ought not to be intrusted to in-
JOHN L. NORRIS, H. D. 249
competent hands. Undoubtedly one of the greatest dangers at-
tendant upon the practice of obstetrics by midwiyes is gonor-
rheal ophthalmia.
Those who are acquainted with the practices of the ignorant
midwiyes know that their usual treatment for inflamed eyes is
to squeeze a little breast milk into them. Some few apply a
little boracic acid. Some place the child in a dark room and
do nothing. They usually attribute the inflammation of the
eyes to cold or to exposure to light. Where the employment
of a midwife is necessitated by poverty it is indeed unfortu-
nate, if through carelessness or ignorance, a child is allowed
to become blind. But it is especially deplorable when through
a sense of modesty or unnecessary parsimony a person finan-
cially able to pay competent attendants employs an ignorant
midwife to attend at confinement and later finds that the
inflammation of the eyes of the infant, which the midwife
told them was but a cold and which later resulted in partial or
total blindness, was a disease which could have been easily
prevented and which any competent attendant would have
recognized and promptly treated had -he been employed.
Should a child die through ignorance of a midwife there is
always the consolation that it might have died under the best
of care, and at most death's wounds are healed by time, but
a blind child whose affliction is due to lack of proper care at
birth is a constant reminder to the parents that they have not
lived up to their obligation.
The following questions have been considered by the com-
mittee:
1. Are there sufficient physicians to attend all cases of con-
finement?
2. Are there sufficient hospital accommodations for all ob-
stetrical cases which would be benefited by hospital
care?
The members from Virginia agree that in the more densely
settled sections of the State there are a sufficient number of
physicians and sufficient hospital accommodations to care for
all obstetrical cases, but, that in the rural districts there are
times when the services of the midwife are the best that can
be obtained. The consensus of opinion is that it would be in-
advisable at the present time to enact legislation which would
prevent the midwife from practicing in the State of Virginia.
In North Carolina the members do not agree as to the neces-
sity of midwives. One member states that there are suffi-
cient physicians and hospitals to afford proper care for all
250 REPORT
cases of confinement and that the midwife evil should be
eradicated. Two other members from the same State are of
the opinion that the midwife is still a necessity. It may be
that conditions in North Carolina are similar to those in Vir-
ginia, namely, that in portions of the State the services of a
midwife are not required, whereas in other sections it is a
choice between employing a midwife or leaving the cases of
confinement to be attended by persons even less fitted for the
work.
In West Virginia it is stated that there are a sufficient num-
ber of physicians to care for all cases of confinement and that
the midwife is not a necessity.
There are sufficient physicians in the District of Columbia
to attend to all cases of confinement. There are in the hos-
pitals of Washington 387 beds available for obstetrical cases,
of which 245 are for those unable to pay for treatment. As
there are about 7,000 births in the District of Columbia each
year, it will be seen that there should not be any difficulty in
securing proper attention. However, there are many persons
in the District of Columbia unwilling to accept hospital treat-
ment and unable to employ a physician who demand the serv-
ices of midwives.
There can be no question but that the midwife conditions
in the southeastern section of our country, as in other parts
of the United States, are far from satisfactory. A prime
object of this association should be to so educate the people
that they will fully realize the dangers attendant upon child-
birth. Then, and not till then, will the midwife problem be
settled and the great mortality of infants be reduced.
SESSION ON CONTINUATION SCHOOLS OF
HOME MAKING
PUBLIC SCHOOL EDUCATION FOR PREVENTION OF INFANT
MORTALITY
(THIRD CONFERENCE)
Saturday, November 15, 1913, 8 P. M.
CHAIRMAN
DR. HELEN C. PUTNAM, Chairman of Committees on School Hygiene
in American Academy of Medicine and. National Education Asso-
ciation, Memler of National Council of Education, Providence
SECRETARY
PROF 1 . ABBY L. MARLATT, Department of Home Economies
University of Wisconsin, Madison
Topic: Methods and vocational objectives in teaching care of
infants tinder one year of age to girls (young women) of sixteen
years and over in continuation schools (or classes) of home making
CHAIRMAN'S INTRODUCTION:
The interests of the American Association for Study and
Prevention of Infant Mortality touch public schools at three
prominent points :
1. The first point of contact is the personal health of future
fathers and mothers as affected by school environment and by
educational processes.
2. The second point of contact is the health standards and
health habits developed in these future home makers by public
schools.
251
252 CONTINUATION SCHOOLS OF HOME MAKING
The former, personal health, has been dealt with in the
schools to a large extent by officials only (architect, commit-
tees, principal, teacher, janitor and supervisors, medical in-
spectors and school nurses occasionally), the pupil being a
passive, unintelligent, helpless subject. The latter, pupils 7
standards and habits in health matters, it has been attempted
to develop by printed and spoken statements more or less
incorrect, unimportant, or inconsistent with school practices
especially such theoretical teachings as concern good air,
cleanliness and exercise. Health habits educate more than
health maxims.
The Association should be very alive to the present effort to
have pupils cooperate in standardizing sanitary details. Such
cooperation is the only effective solution of a large part of the
difficulties I have mentioned in growing children up to healthy
parenthood with correct health standards. It is quite funda-
mental to general popular appreciation of high temperature
and humidity as a cause of infant mortality, set forth in
another section yesterday. The custom of pupil health officers
is spreading rapidly.
The Traveling Exhibit that is shown here accompanied by
the following summary of the report by my committee in the
department of science instruction of the National Education
Association is being used by normal and high schools and
teachers' organizations to stimulate work along the lines sug-
gested. The opening sentiment of the exhibit, as you see, con-
nects with our work : "Better parents of better children should
be the aim of public schools."
To standardize janitor service, or school housekeeping, the
first step is to get the facts. Every building, as every room in
it, has its own conditions to be learned and controlled.
This can be done with least expense and greatest effective-
ness by enlisting pupils' co-operation. Expense is negligible.
Effectiveness is along three lines: I. Practically constant
supervision which good housekeepers find indispensable; 2,
permanent records of sanitary details in place of guesses and
opinions ; 3, interest of future voters and home makers in such
details by practice in regulating them.
Health Officers. Appoint a group of health officers in each
classroom, for periods so limited that each child has service
once a year. Credit their work to "physiology and hygiene,"
or "nature study," "domestic science," physics, chemistry,
biology.
Temperature. Health officers shall read thermometers
hourly, record readings in a substantial book, chart them (e. g.
nurses' clinical charts) on a blackboard reserved for it, where
HELEN C. PUTNAM, M. D. 253
pupils, principal, janitor and visitors can see perhaps a week's
record at a glance. When conditions permit they shall readjust
heat sources, ventilators or windows to secure proper tempera-
ture which, when artificial heat is used, should never exceed
68 degrees Fahrenheit. Pupils over eight years of age can do
this; sometimes younger.
Dustiness. In high schools health officers can measure or
estimate it by cultures, or by the "sugar method" recommended
by the Committee on Standard Methods for the Examination
of Air. The standard is 2,000 particles (visible under a two-
thirds inch objective) to a cubic inch of air.
In elementary grades they can wipe surfaces with a clean
cloth. If dusting was properly done, nothing is wiped off.
Floor, woodwork and furnishings should be as immaculate as
in the best kept home or hospital. This test should come at
the beginning of the session.
Health officers should be responsible for the moist erasing
of chalk, but pupils should not be required to dust rooms.
Officers should record sweeping of room or corridor while
pupils or teachers are obliged to use the rooms. (Severe pen-
alties for this violation of sanitary rights should be enforced
by school boards.)
Elementary pupils over eight years of age can do this, in-
cluding record keeping.
Relative Humidity. Officers over eleven years of age can
be taught to use safely the whirling wet-dry bulb thermometer
recommended by the TL S. Weather Bureau. The danger of
breaking is lessened by tying to the back a stick projecting a
few inches beyond the bulbs. One instrument is enough for an
ordinary building. Relative humidity should be recorded and
charted about a half hour after the session opens. It can
well be done later also. Where possible officers shall readjust
artificial sources of humidity (evaporating pans, steam radia-
tors, etc.), or windows, to maintain relative humidity at 50
per cent.
Air Currents. When ventilating flues have no current
indicators of their own, officers should measure currents with
an anemometer (one is enough for the usual building), or esti-
mate them with candle or joss stick. Pupils over eleven can
use them, perhaps younger. The effectiveness of air currents
is best learned by comparing the smell of schoolroom air with
that out of doors the standard of freshness. Air currents
and freshness should be recorded at least once at the middle
of each session. Officers should make such readjustments of
windows or ventilators as indicated.
Cleanliness. Cleanliness of washbowls, waterclosets, and
of any other part of building or yard should be recorded once
each session. Dirt on windows sometimes diminishes illumina-
tion one-quarter to one-third, measured by a photometer. The
Instrument is costly, and until a less expensive method is
devised the opinion of health officers can be given. Dirty
254 CONTINUATION SCHOOLS OF HOME MAKING
windows are important in rooms badly ventilated or specially
exposed to smoke and dust. Such windows sometimes need
washing once in two weeks. Pupils over eleven, possibly
younger, can do this reporting.
General Suggestions. Health officers from older grades
can be appointed for rooms where pupils are too young for
any special detail,
When a fault is found beyond pupils' function to remedy,
it should be reported immediately to the proper authority,
probably the principal. It is wise never to "interfere with
the janitor." This report and the results following should be
stated in ''Health Officers' Permanent Records."
For other than classrooms and for corridors groups can
be specially appointed, their duties being suitably modified.
Some, if not all of these esercises in practical sanitation
can be undertaken quietly at any time by any teacher in
charge of any room. One or the other is already proved prac-
ticable in individual schools within the last ten years. The
accumulated data will be invaluable. It is the practical first
step in reducing "school diseases," including tuberculosis,
which increases all through school years (except in open air
schools), and among teachers has a mortality rate higher than
among the general public.
These facts will help demonstrate that school housekeepers,
like others, must be trained in sanitary methods. Janitors'
salaries and their Supervisors' often equal and sometimes ex-
ceed salaries of teachers, principals and other trained workers
whose responsibilities are no more serious, and who are care-
fully prepared and tested before appointment.
3, The third point where the interests of the Association di-
rectly touch public schools is in the instruction given and that
should be given to fit boys and girls technically for the vocation
of home making with special reference to responsibilities for
infant life.
Our two preceding conferences on continuation schools of
homemaking discussed needs and conditions for free school
instruction continued through adolescence and early maturity
for this purpose, to meet the needs of approximately 20,000,000
young men and women with but a fraction of our' elementary
school instruction, approaching marriage and parenthood with
only such additional knowledge as has been picked up from
irregular sources. During these two years, in accordance with
a resolution of the first conference, we have petitioned each
state board of education to secure the appointment of a com-
mission to study conditions and needs in its state, and to
report effective plans for meeting them through such continua-
tion schools and classes. We have also sent reports and re-
HELEN C. PUTNAM, M. D. 255
prints to several thousand superintendents and other educa-
tors, and have urged the matter in several educational journals
with largest circulation and influence.
It is reasonable to believe that this effort has had some effect
in determining the fact that whereas, four years ago almost
exclusive emphasis was laid on commercial aspects of voca-
tional (continuation) schools, at present the states, cities and
organizations engaged on the problem are more and more
including health and its related interests in planning courses
for either sex; hygiene and sanitation concerned with the voca-
tion, and their effects on the family as well as on the workers.
We may also congratulate ourselves on the increased atten-
tion given to infancy in courses in home economics in our great
universities, colleges and certain special schools. The univer-
sities of Wisconsin, Kansas, Missouri and others are develop-
ing model methods not only in their special departments, but
also in extension courses attended by many thousand married
women annually, and even in correspondence courses. Insti-
tutions such as these not only mold the young women and
men of their states but they supply public schools and other
schools with teachers having this higher viewpoint of life and
the training to impart it to others.
Important reasons -have led to the topic of this session:
Methods and vocational objectives of teacMng- care of infants
under one year of age to girls (women) sixteen years of age
and over in continuation schools (or classes) of homemaking.
One is a psychologic reason. The usual individual in years
of possible parenthood, early years especially, does not will-
ingly make the possibility a definite object of public attention,
for obvious reasons that are good. So far as the education
itself goes, it can be acquired in its several phases while train-
ing for mothers' helpers, agents of health boards, housekeepers,
homemakers, janitorial service, or in preparatory courses for
regular training schools for nurses. Even the medical profes-
sion is finding that it is rooted in the public schools, and cer-
tain improvements desired for all the people would be to its
own advantage; for example, elementary understanding of
certain fundamental laws in biology and in sanitation, such
as primary school children find fascinating when they are so
fortunate as to have a competent teacher, would make better
physicians as well as better parents. These continuation
schools can develop still more of this desirable common knowl-
edge. High schools and extension courses of high schools may
answer the purpose.
256 CONTINUATION SCHOOLS OP HOME MAKING
Another is an economic reason. By combining training for
these several vocations in one school, the same special officials,
teachers, apparatus, buildings, can be more fully utilized, cer-
tain elementary instruction being needed by all. Divergence
later in the course with special vocational diplomas is entirely
practicable.
The comments of Professor Marlatt, in the pages following
on some of these points, and on the avoidance of the abnor-
mality of introducing infants and their care in elementary
schools, deserves attentive reading. Certainly it would seem
that the government through its schools should aim at the
Etormal. There is never lack of leaders in social departures
from biologic law under plea of expediency. It is essential
that the Association merit public confidence by squaring our
teachings with this law so far as we understand it. The
nation undermines success that through its schools condones
for industrial exploitation the separation of mothers and
babies, and helps to give the immature the responsibilities of
mothers. It hinders efforts to develop popular appreciation
of the greatness of parenthood by belittling the name of mother
(or father) to the status of a child. To "help mother" is the
wholesome mental attitude in all the little services children
may properly be called on to render.
SPECIAL COMMITTEE REPORT (Read by the Secretary)
Prepared by MISS MARLATT, MISS EMMA S. JACOBS,
MISS ALMA BIIVZEL and MRS. VANDBRVORT
CONTINUATION SCHOOLS OF HOME MAKING
One Phase of the Curriculum Methods of Teaching Care of Infants
Under One Year of Age
A. Vocational Objectives
1. Mothers' helpers -
2. Board of health agents
a. Visiting nurses
b. Sanitary inspectors
c. Visiting housekeepers
3. Preparation for parenthood
B. Essential details in curriculum
1. Courses of study (suggested in outline)
a. For mothers' helpers
b. For agents of board of health
c. For future and present parents
0* Methods used
1. Brief reports from some European experiments
2. Brief reports from American experiments
a. Day nurseries as laboratory
b. Helper to visiting nurse
c. Use of manikins in regular laboratory classes
supplemented by visits to children's hospi-
tals, etc.
B. ESSENTIAL DETAILS IN CURRICULUM
The problem under discussion, to train girls between the
ages of 16 and 30 so that they may intelligently care for infants
under one year of age, is further limited by the fact that the
instruction to be given in continuation schools, must in prac-
tice be given in either day continuation schools or night con-
tinuation schools. If the pupil has remunerative employment,
then the number of hours that may be allotted to such defi-
nite subjects per week is limited either by state law or by
257
258 CONTINUATION SCHOOLS OF HOME MAKING
city regulation. As the majority of the states have a compul-
sory school age limit of from 14 to 16 years, this means that
the average girl of 16 years will have had the opportunity to
complete, and if she has the ability, will have completed the
grammar school requirements. While it might not be expedi-
ent, or even desirable, to insist upon these requirements in all
cases for entrance in these continuation schools, still the work
below the grammar grades should not be forced into the voca-
tional schools except in cases where it may be fundamental
to the training of the foreign born who do not understand the
use of our language. With the vocational objective in view
as indicated in our program, the following subjects are recom-
mended according to the future work to be followed.
I. Mothers' Helpers
Physiology of growth
2. Hygiene general and personal
3. Child study
4. Care of infants :
a. Physiology of growth
b. Hygiene of infancy
c. Bathing the infant
d. Clothing the infant
e. Food for the infant
5. Sewing (hand and machine)
a. Infants' wardrobes
b. Cost of clothing
6. Laundry work
a. Fine woolens
b. Lingerie
7. Principles of cookery and art of cookery
8. Housewifery
While this is a specialized course of study, it will give the
professional training as well as the fundamentals which are
so essential to the training of the girl for the work nature
intended her to do.
IL Agent of the Board of Health
The courses of study necessary for those who are to act as
agents of boards of health
COMMITTEE REPORT 259
a. Visiting Nurses
The visiting nurse must first of all be a graduate nurse,
preferably from a three years' hospital training course. Con-
tinuation school work may be given her as follows :
1. English
2. Psychology
3. General sociology
4. Poverty and relief
5. Cooking and nutrition
6. Dietetics
7. House sanitation
8. Household management, including house-
wifery
b. Sanitary Inspectors
Sanitary inspectors should, if possible, be women of col-
legiate education or its equivalent, who have majored in
Bacteriology, Foods, and Housing Problems, and minored in
general Economics, and Poverty and Belief. Such a worker
should preferably be trained in schools of civics or philan-
thropy. It is doubtful if the continuation school, without it is
equivalent to such training, would answer the purpose.
c. Visiting Housekeeper
The visiting housekeeper should preferably be a woman of
wide education, maturity, and experience, who should have a
systematic training in the vocational schools in the following
subjects :
1. Cookery
2. Food values
3. Textile studies
4. Housewifery
5. First aids
6. Care of the sick, or, home nursing
7. Household management
8. Applied psychology, as psychology of sugges-
tion
9. Poverty and relief
The visiting housekeeper has one of the most difficult prob-
lems, and therefore requires the broadest human interest, and
the maximum amount of tact in reaching the people to whom
she is sent.
260 CONTINUATION SCHOOLS OF HOME MAKING
III. Preparation for Motherhood
The third class who should be provided for by these con-
tinuation schools in homemaking, are the future parents and
the present parents. The following course is suggested as
being one that would meet the present and future needs :
1. Physiology and hygiene
2. Simple biology, possibly under the name of ad-
vanced nature study, studying the lower life forms
up to man
3. Eugenics in its broad aspect
4. Bacteriology as applied to house and food supply
5. Food work under the following topics :
a. Cooking
b. Marketing
c. Dietetics
6. Textiles
a. Manufacture
b. Tests for adulteration
c. Lessons in buying
7. Sewing
a. Hand sewing
b. Mending
c. Machine sewing
d. Garment making, including children's cloth-
ing and some dressmaking
8. Housewifery
9. House management
10. Psychology
11. Child study
12. Care of the infant :
a. Physiology of growth
b. Hygiene of infancy
c. Bathing of the infant
d. Clothing the infant
e. Food for the infant
13. Care of the sick:
a. First aids
b. Home nursing
C. METHODS. Discussed by Prof. Marlatt
From reports and from replies to personal letters to leading
educators in Europe, it would seem that most of the countries
are in the same condition as the United States in their realiza-
tion of the need for vocational training in schools of home-
COMMITTEE REPORT 261
making for girls of sixteen years and older. While there have
been certain important centers like the Pestalozzi- Frobelhaus,
in Berlin, established in 1873; a school in Brussels; The
School for Mothers, at Ghent; the Sesame House in St. John's
Wood, London; the Ecole d'hygiene d'education familiale et
sociale d'enseignement menager, in Paris, who have quite a
number of large training schools in connection with the chil-
dren's homes, orphanages, and kindergartens, yet they have
not reached the large mass of the people, which is the aim of
the continuation schools of homemaking as here outlined.
Fraulein Helene Menzel says, in regard to the present work
of the continuation schools for girls in Germany: "It is to be
regretted that in our newly organized continuation school for
girls, the education for housekeeper and mother is only sup-
plementary to the commercial education which is paramount.
My personal view would be to give our girls, above all, the
education to which nature has destined them, and there should
be a well organized correlation between hospital, infant asylum,
cr&ches, cooking centers, etc., and there should be enough
schools so that every girl would have a chance to be well equip-
ped for her life work. But today this is an aim 'Devoutly to
be wished.' "
Since 1907 Prussia has attempted to deal with the continu-
tion school problem for girls, and has established state schools
for the training of vocational teachers with the result that
other parts of Germany have followed the Prussian plan.
While in 1900 the continuation schools were made compulsory
for female commercial clerks and apprentices, it was not till
1911 that the continuation schools became compulsory for all
their female employees. As these were for the perfecting of
the girl in the line of work in which she was employed, it left
out the problem for the training for her future usefulness.
At Easter, 1913, the obligatory continuation school for girls
was founded in Berlin. In this the teaching of Domestic
Economy must be given six hours per week to all office clerks,
shop assistants, dressmakers, milliners, and seamstresses, while
in the case of untrained workwomen, the teaching of domestic
economy occupies half of their school time. It was to this
limited amount of time given to the home problems that Frau-
lein Menzel refers in the letter previously quoted.
This means that Germany has made the decided stand for
compulsory education which will in a measure train the girl
fo* motherhood.
262 CONTINUATION SCHOOLS OF HOME MAKING
Prom data sent me from the American Embassy at Vienna,
the extension work offered by the University of Vienna 1912-13
is given, and proposed work for 1913-14 is indicated.
"Lectures for Brides" is the name of the latest course started
by the Extension Department of the University of Vienna. It
is known as the Urania, and is now advertised all over the
city. Although mainly intended for those who are about to be,
or have just been married, all girls over seventeen years will
be admitted. The course lasts for eight months, there being
lectures on two evenings a week. A small fee is charged for
the course, but the poor can obtain tickets free. The program
for 1912-13 was as follows :
BRAUTKURZE
I. Food for the person in health. Dr. Karl Schwartz;
October 11, 15, 18, 22
II. 1. Woman in the kitchen. Dr. Victor Grafe; November
5, 8, 12
2. Woman in the kitchen. Director Johann Michael
Heitz
3. Summer and winter menus. Mrs. Marianne Stern ;
November 15
4. Secrets of the washing and cleaning processes. Dr.
Eichard Schwartz; November 19
III. Food for the sick. Dr. Hugo Salomon; November 22,
26, 29 ; December 3
IV. Care of the Health in the Family. Dr. Eoland Grass-
berger; December 6. 10, 13, 17
V. Cosmetics. Dr. Leo Eitter von Zumbusch ; January 10
VI. Food and care of infants. Dr. Eobert Dehne ; January
31 ; February 7, 11, 14
VII. 1* The mother as the first teacher of the child. Dr.
Alfred Kolisko ; February 18
" 2. Sicknesses of children. Dr. Fritz Passini; Febru-
ary 21, 25, 28
3. Song and art in the nursery. Mrs. Erika Spann-
Eheinsch Briin ; March 4
VIII. Care of the sick and first aids in the house. Dr. Max
Scheimpflug; March 7, 11, 14
IX. 1. Dangers in Housekeeping. Dr. Fritz Eeuter; March
18
2. How can the housekeeper protect herself against
being overcharged in marketing? Dr. Eichard
Schwarz; March 28, April 1 and 4
COMMITTEE REPORT 263
3. Correct values of food. Dr. Henry Beichel; April
8, 11
4. Foods and confections their substitutes and adul-
terations. Dr. Victor Grafe; April 15, 18, 22
X. 1. Economy in housekeeping. Dr. Henry Nubel;
April 25
2. The status of the wife in the household. Mrs. Elsa
Beer-Angerer ; April 29, May 2
3. The status of the housewife in relation to the serv-
ants. Mrs. Olga Misar; May 6
XI. 1. Women in charity work. Dr. Otto Maresch; May
9
2. The comfortable dwelling house. Mrs. Elsa Brock-
hausen; May 16, 20, 23
3. The readings, or courses in reading for the wife and
housekeeper. Dr. Maria Jesewicz; May 27
4. The social life of the housemother. Dr. Maria Jese-
wicz ; May 30
SUPPLEMENT TO THE BRAUTKURZE
The housewife in the kitchen. Dr. Victor Grafe; November 20
Gas in housekeeping. Hans Giintner; January 16
Electricity in housekeeping. Albin Gigl; January 23
Life before birth. Dr. Blanca Bienf eld ; January 30
Woman and athletics. Dr. Max Eugling; February 6, 13, 20,
27
Eights of the family. Professor Stephan Brassloff ; March 6, 13
Bights of society. Dr. Edmund Krautman. March 27, April 3
Eights of the public. Dr. Rudolph Harmann zu Herrnritt;
April 10
PROGRAM FOR OUR BRAUTKURZE 1913-14
[From Neues Wiener Tagblatt]
"We have already spoken of the change in the organization
of the Women's Course which will make it more profitable for
the pupils ; the program for the future is more comprehensive.
Some series of lectures, which last year were received with
lively interest as giving much useful and practical inf ormation,
will be much extended. In this direction we offer the lectures
upon food and the culinary art, instructions upon marketing,
upon the furnishing of the home and the arrangement of the
works of art in it ; upon the care of the body, the hair, teeth,
skin, etc. Selected lectures by specialists upon mental and
264 CONTINUATION SCHOOLS OF HOME MAKING
physical work. Four lectures upon artistic dress and fashion :
'Every Day Dress/ 'Company Dress, 7 'Dress for Travel and
Sports/ 'Ornaments and Jewels.' The hygiene of clothing
and the purchase of goods will receive special attention. Eight
lectures will be given upon the social and pedagogical duties
of woman in family and public life. The program of the
brides' course extends far beyond a housekeeping course and
embraces everything in its province, which enhances the indi-
viduality of woman.
"LECTURES IN THE BRIDES' COURSE OF THE URANIA OF VIENNA
FOR THE COMING SEASON
"The Urania of Vienna has chosen for the various courses
of lectures in the Bride's Course, distinguished experts, skilled
in their special studies.
For foods in general. Dr. Graf e.
Nourishment for the Invalid and the Person in Eobust
Health. Dr. Salomon.
"Dr. W. Schlesinger together with Fraulein Frerich and Mrs.
Marianne Stern will conduct the scientific and practical les-
sons on the table, the kitchen, the culinary art, giving particu-
lar attention to the dietary kitchen. For the development of
economical and technological knowledge in the purchasing of
foods and necessary articles, the lectures of Dr. Eeichel, Pro-
fessor Grafe, and Dr. Eichard Schwarz have been secured.
"Dr. Eeuter and Dr. Hiibel in connection with Mrs. Olga
Misar will give instruction upon technical and economical
subjects pertaining to housekeeping.
"Dr. Strnad, of architecture, will lecture upon art in the
bailding and furnishing of the home, and supplementary to
ty& Dr. Jesenko will give talks upon the culture and arrange-
ment of flowers and the care of house plants.
"The care of the body and the proper and safe use of cos-
metics will be taught by Dr. Elsie Volk, Dr. von Zumbusch
and Dr. Ewald.
"Questions in regard to artistic fashions and dress will be
answered by Mrs. Natalie Bruck-Auffenberg.
"An instructive lecture upon ornaments and the goldsmith's
craft will be given by Dr. Ernst, custodian of the museum.
"The social and legitimate status of women, as well as the
public services demanded of her will be taught by Mrs. Helene
Granitsch and Use von Arlt.
COMMITTEE REPORT 265
"Dr. Dehne, Dr. A. Kolisko and Dr. Sperk will have charge
of the instructions upon the care of young infants and small
children.
u Mrs. Helen Scheu-Kiess will discuss some problems in the
first stage of education.
"In all classes, there will be introduced hygienic lectures in
close relation to the subjects under consideration. These lec-
tures will be given by Dr. Grassberger, Dr. Eeichel and Dr.
Eugling. ;;
In both Switzerland and France the girl between the ages of
ten and fourteen is taught in the public schools by lectures and
demonstrations how to care for infants, but so far I can get
no data as to the training in vocational schools beyond the
years of sixteen, so that the pupil may be classed as a profes-
sional mother's helper.
In Brussels, I am informed, more systematic work has been
done, as there the girls are taught the care of infants, first
through use of manikins, and later by going each week to chil-
dren's hospitals and foundlings' homes, and practicing on the
living infants.
In England, Ella Pycroft, reporting from Virginia Water,
Surrey, England, states that while the age limit in England is
fourteen years, the girls over twelve to thirteen years are al-
lowed to leave the school after having reached the desired
standard of education. It is customary to leave the two courses
of laundry and cookery work till the last years of the girPs
school life, and following this they are sent to the housewifery
center where they are given lessons in sick nursing, care of the
infants, young children and first aids.
The children used in the practice work in the Wales schools
at Glamorganshire, have been practically the brothers, sisters,
cousins, or friends of the pupils. The outline of their work is
as follows :
Care of children, five weeks
Making cheap toys, preparing a nursery, characteristics
of children
Lesson on bathing an infant
Preparation of infant food, making of clothes
Jennie L. Calder, of Liverpool, in speaking of the evening
technical schools, says that the difficulty is that so compara-
tively few take advantage of them. That what is needed is
"day schools of domestic science only, for a course of at least
six months to be made compulsory for every girl before her
266 CONTINUATION SCHOOLS OF HOME MAKING
education is finished; where undivided attention can be given
to the business of creating (the sorely needed) 'Makers of the
Home.'
a To take the example of one such school that is fully equip-
ped for teaching all that is connected with home management,
and that has also overcome the difficulty of providing a real
basis upon which housewifery can be efficiently taught. This
is a day school like any other, open morning and afternoon,
every day but Sunday. A six-months' term is prescribed, i, e.,
twenty-one working weeks.
"The subjects taught are cookery, laundry work, household
sewing, home dressmaking, domestic millinery, upholstery, sani-
tation with hygiene, housewifery and the care and feeding of
infants a long list, truly, but they work in with each other, and
some can only be taught by demonstration lectures. No sub-
ject is taken for more than a week at a time, i. e., a girl will
have a week of cookery, then a week of dressmaking, then a
week of laundry work, and so on, each in turn, the cycle being
repeated over and over again."
These are brief reports from some European schools.
In America, the teaching of the care of infants under one
year of age has been along the line of training girls of from
ten to twelve years of age to be "little mothers/' a training
which is considered by many to be physiologically and possibly
morally wrong, in that the child is too immature in physique
and in judgment to have this burden put upon her. It is a
form of teaching that commends itself because it can be given
during the years of enforced attendance at the public schools,
but psychologically it is given to the girl when she does not
appreciate the need of it and hence it fails of its highest good.
A few private schools have offered courses which lead to the
expert knowledge in the care of the child. One of these is
modeled on the work done at Sesame House in London. This
course of study includes the following topics :
The family its psychology, sociology, ethics
Biology eugenics
Physical care of infants and young children
Child hygiene and physical development
Dietetics children's cooking, laundry sewing
Marketing housewifery; accounts; management
Home care of sick children ; emergencies
Hygiene for mothers
COMMITTEE REPORT 267
Child psychology and mental hygiene
Principles of child training and of the kindergarten
Children's stories, games, songs, handwork, nature study
Such schools have been in existence too short a time to
measure the results of such philanthropic efforts.
Missouri University attempted at one time to teach the care
of infants by demonstrational methods but the public was not
educated enough to appreciate the need of laboratory practice.
There are three possible methods of securing apprentice
work. First, where continuation schools are in close affiliation
with the day nurseries or churches connected with factories or
shops. In these both by demonstration and later by practice,
the washing, dressing, and proper feeding of the baby may be
learned.
The second method, which is to allow a pupil in the later
part of her study to accompany the visiting nurse acting as
her helper, thus gaining the necessary skill under direction,
will have a limited use as not more than one pupil could prac-
tice at a time.
As a rule the visiting nurse, or visiting housekeeper, is wel-
come only after tactful methods have been employed by the
physicians and head of associated charities, hence there may
be serious objections to this second method, as nothing which
may jeopardize the successful work of the visiting nurse is
admissible.
The third method, which consists of regular laboratory prac-
tice work on suitable manikins, seems most nearly feasible.
This method is now in use in at least one university where
students go thru all the steps from changing the dressing on
the cord to the complete dressing of the infant. This work is
supplemented by visits to the hospital where infants only a
day or two old are washed with oil and then dressed before
the students in the clinical operating room. If the hospital is
one where foundlings are received it may be possible for the
students to help, but the child of the "private patient" may
not be even used in demonstration classes.
In continuation day schools the training to be semi-profes-
sional helpers for mothers, visiting nurses, etc., may be gained
best by practice on manikins and later by work in day nur-
series under careful supervision.
The use of a young baby in the school room is very question-
able because of danger from infection and also because of
more or less nervous strain which comes from unusual environ-
ment and noise.
268 CONTINUATION SCHOOLS OF HOME MAKING
In this discussion I have tried to make clear how we can use
continuation schools for training mothers' helpers. Of the
seven million working women in this country, out of our total
forty-five million females, at least eighty per cent will marry
and bring children into the world. Anything that we can do
to help them prepare for their life work we should do. If we
train girls to help the mothers, they will be in possession of
invaluable knowledge for their own homes.
In the discussion by one of the speakers yesterday there was
an earnest plea made for the training of young girls as little
mothers so that in our large cities the foreign and uneducated
mother could be helped through training the young girl to take
the burden of the care of the infant, brother and sister. While
we recognize the value of such assistance and realize that it
may be the line of least resistance in such cities as New York
where the foreign speaking population is so great, still I wish
to call attention to the fact that this measure is for expedi-
ency only and therefore we should not foist upon the general
system of vocational educational for the United States a
method which is distinctly physiologically and psychologically
bad but has for its excuse the easiest way financially to meet
a very serious problem which otherwise would have to be
handled by a large corps of district nurses speaking the lang-
uage of the immigrant concerned.
DISCUSSION OP COMMITTEE REPORT
MISS EMMA SUTER JACOBS, Director of Domestic Science,
Schools, Washington, D. C.
Before we can discuss courses of study for any subject we
must agree upon certain things, especially upon the funda-
mental definitions. What is the home? Where is it? What
it its use or function? These are the questions which might
be asked, and the answers will be as different as the persons
giving them, but I believe we will agree on these fundamentals ;
that home is something more than a place where one's meals
are served, or where one sleeps or keeps his clothes, and that
the essential characteristic of a home is that it is a place
where human beings joined in family groups, may get away
from the business world, relax the whole being, and develop
or give expression to that which is the individual self in each.
In this home we gain the power and repose of spirit which
is necessary to fight life's battles, which is necessary indeed
for life itself. It is here that the young of the race receive
their first lessons; are given their ideals; and where their
habits are formed.
Woman is the natural home-maker for she is the mother.
I believe that at some time all women have some mothering
to do, although they may never have children. Into the hands
of women is given most of the care of children. I would not
be understood as exempting the men, for I believe the man's
influence is needed for perfect development of children.
The public school education does little to fit her for home
making, and until recently has done almost nothing for the
girl. It gave her for her most important part in it such train-
ing as it gave the boy, who is naturally the bread winner or
provider for the home; yet she is to be the spender of this
income; hence the homes which these girls made did not
function correctly and both the girls and the boys, now grown
to be men and women, became dissatisfied. Neither realized
what a home should be. The result is, we find men and
women hesitating to join hands and make homes. There are
many children in this land who are not provided with the
right home environment, hence the self in each does not have
opportunity to attain full development. Therefore systematic
training must be given along lines which will teach our
young people how to make homes, homes where the children
will be given full opportunity to reach the highest possible
development of self, and where the adult may be refreshed, re-
269
270 CONTINUATION SCHOOLS OP HOME MAKTING
newed and uplifted day by day. We turn to the schools, for
it is there that systematic teaching can be given, and ask that
they make provision. Now, what can the schools do? This
specialized training cannot be given in the primary grades
because the children are too young to profit by it, even if they
could understand it. Moreover, they would forget it long be-
fore they had opportunity to put the teaching into practice.
A start may, however, be made in the grammar grades by hav-
ing what is termed home schools, where the routine of house-
work and the elements of cleanness and sanitation may be
taught; also cooking schools, for teaching things concerning
foods. The home schools should be located in small houses
in the neighborhood of the school and furnished simply but
beautifully, and in such way as to create an ideal.
In these grades the children are between 13 and 15 years
of age. Old enough to profit by the teaching by putting it
into practice when helping their mothers at home, yet they
are young enough to enjoy the play element which must enter
into this work in the home school. The work of the home
school was begun on a small scale in this city last year, and
we are asking for opportunity and means to do more, but
cooking schools have been in operation here for 26 years.
Further, all girls in the high schools should have at least
two years' work along lines which will train specifically for
homemaking, as this brings the training nearer to the time
when it will be needed and the work can be given with a
science background.
But this does not reach all, for in every city there are many
who leave school before reaching the grade or age where such
training can be given, hence for such the continuation school
should be established and courses be provided for training
along one or more of these lines :
1. Mothers' helpers
2. Agents of the board of health
3. Homemakers
The training of mothers' helpers, I believe, is a good voca-
tional line of work for our girls who must leave school early
to earn a living. Many mothers need and desire help in car-
ing for their children, and are gradually learning the neces-
sity for having trained helpers. Tor such a school I present
the following course of study, the pre-requisite to be good
health, good habits, good morals, and the common school edu-
cation (through the eighth grade, if possible).
EMMA SUTER JACOBS 271
COURSE OF STUDY FOR MOTHERS' HELPERS
1. Fundamental principles and practice of cooking
2. Preparation of food for infants and young children
3. Principles of feeding children from infancy to five years
of age
4. Elementary physiology and hygiene, with emphasis on that
of young children
5. Elementary principles of housekeeping and sanitation
6. Plain sewing and garment making for children
7. Story telling, games, and other means of amusement,
which would embody some of the principles of the kin-
dergarten and Montessori systems
8. Care of childhood emergencies and sick children
Those who complete such training would be something more
than the ordinary nurse girl of today. They would be more
valuable to the mother, and have a work to do as noble as
that of the trained nurse.
To make such a school successful an infant's school, or a
day nursery should be joined with it, so the students could
be given opportunity for observation and practice, as in all
normal schools for the training of teachers. It might be
well to let students spend part of the time in a children's
hospital. By the infant school I mean a school where children
below the kindergarten age of five or six years would be taken.
Such schools should have large playgrounds, garden plots,
sheltered open-air play spaces, sleeping accommodations and
a kitchen.
This course should be open to graduates and under-gradu-
ates of the high schools, as well as to those who do not enter
the high school, and should be for at least one year, prefer-
ably for two years.
A registry or employment department is also essential to
the success of this work.
COURSE OF STUDY FOR Ho ME MAKERS AND PARENTS
1. General principles and practice of cooking
2. General principles of dietetics planning meals special
feeding
3. General principles of physiology, hygiene and sanitation.
(Would include subject of prenatal period.)
4. Simple nursing care of emergencies and communicable
diseases
5. General principles of housekeeping
272 CONTINUATION SCHOOLS OP HOME MAKING
6. Sewing, garment making and repairing
7. Child study, under which would include elementary psy-
chology; story telling and reading; value of play and
suggestion ; reward and punishment ; influence of hered-
ity and environment
8. House planning and furnishing. (In this connection the
model house should be the place of meeting so the study
of its arrangement and furnishing could be concrete.)
9. Use of carpenters' tools
10. Simple chemistry, physics, biology and eugenics
11. Keeping accounts and division of income
The work should be given by means of experiment, demon-
stration, lectures, discussions and practice. Several series of
lectures, or rather talks should be arranged for both men and
women, for the men also need to be trained for this important
function.
The course for board of health agents I have not worked
out, but I have been considering it and feel that the broadest
possible education in science, economics and sociology is
needed. This is certainly a collegiate grade of work. This
knowledge must be coupled with practical knowledge of how
to deal with people, and a personality that will win the con-
fidence and cooperation of those with whom these agents
deal.
Such courses as these would certainly give us a trained body
of home makers who would be able to create better environ-
ment and secure better care for the children who are to 'come.
Stronger children will be born, and these will have better
chance to grow to manhood and become constructive forces
in the world.
MISS ALMA BLNZEL, Superintendent of Primary Grades, Missonla,
Montana
I have discussed the matter, and incidentally the outline,
with mothers who are college women (one with special interest
in biology; the other with partial training for nursing and
with experience in journalism). They incline to the opinion
that it is women of their class, wives of professional men, who
know enough to want just such prepared Mother's Helpers but
couldn't make the income stretch sufficiently to pay for a good
one. Hence, their wish was and is better preparation of them-
selves for the task of rearing children, and the sending out and
having done the other aspects of housework. They are agreed
that those wealthier than themselves tend to be less desirous,
ALMA BINZEL 273
less appreciative of such prepared workers and hence need
stimulation into thought on the matter. Both of these groups
of parents are outnumbered by those who neither know nor
could afford if they did know and desire the services of ex-
perts ( ?) with children. For these the day nursery should be
a source of help and information.
Basic preparation for parenthood would in a general way
meet some of the needs of all three groups; theoretically, it
should be compulsory practically, it will not become so for
a long, long time. Theoretically, courses should be planned
for and should be taken by fathers ; their contribution to the
child's welfare is frequently so far below what it might be
because of lack of information. Keenforcement instead of
counteraction of some of the mother's most intelligent efforts
would thus be insured.
A. VOCATIONAL OBJECTIVES
1. Mothers' helpers
Step 1. Educating fathers and mothers to a realization
of the importance of engaging prepared work-
ers. Involves a different attitude toward such
worker than that accorded the average servant
Involves a different attitude toward financial
remuneration than average nurse girl of today
receives.
Step 2. Educating young girls and women to realization
of importance of preparation for what is im-
mediately a pleasant and interesting vocation
and ultimately a preparation for assuming par-
ental duties.
Involves the development of reverence for moth-
erhood ; of appreciation of its complexity ; of its
bearing upon the social good.
2. Board of Health Agents (not analyzed)
3. Preparation for parenthood. Men and women
Step 1. Sane answering of questions concerning origin
of life.
Step 2. Science teaching that makes attitude toward
preparation of species ? reproduction wholesome
and reverential; that establishes healthy inter-
ests in phenomena of all life.
274 CONTINUATION SCHOOLS OF HOME MAKING
Step 3. Amusements guided to satisfy natural craving
for companionship, that foster impersonal pleas-
ures and guard against over stimulation of all
kinds.
Step 4. Eational instruction on origin and development
of the family, the marriage ceremony, the op-
portunities for self-development and the social
obligation in marriage relationship. (This would
include the basic facts of eugenics, laws or facts
of heredity, etc.)
B. CURRICULUM
I. For mothers' helpers
1. Training in personal health, cleanliness, manner, and
study habits, and emotional or temperamental tend-
encies.
2. Instruction in facts of physiology of normal child-
life:
a. Proportions, trend of growth in size and weight;
character of muscle, bone, blood, etc., composition ;
condition and care of sense organs ; etc.
1}. Amount and frequency of sleep ; choice and care of
beds, bedding and sleeping place; methods of put-
ting to sleep; regularity; respiratory system.
c. Amount, nature and frequency of food-taking;
choice and care of foods, their containers and serv-
ers; the digestive system; teeth development.
d. Amount and character of bathing; of soaps, pow-
ders, linens, etc.; the skin and its functions.
e. Methods of establishing toilet habits ; the function
of excretory system.
/. Essentials in number, type, cost, texture, care of
garments.
g. Outings desirable.
The whole growing out of general topic of "Better
Babies Movement" or leading to it as an organizing
motive.
3. Instruction in facts of psycho-physical nature of the
normal child.
ALMA BINZEL 275
a. Meaning, nature and organization of physical
activity of child; of his sense of hungriness; of
consciousness; speech development.
fc. Fundamental methods of acquiring control of self
and environment: haphazard manipulation and ex-
perimentation; imitation unconscious (absorption
of environment) and conscious; instruction; typi-
cal efforts at early education.
c. Nature, value, and process of habit formation.
d. Normal and desirable stimulation through toys,
plays, people.
e. Individual differences in children determine re-
sponse and hence call for varying treatment physi-
cally and mentally.
4. Instruction in facts of sub-normal physical and psy-
cho-physical nature of children
&. Symptoms of inal-nutrition ; imperfectly working
sense-organs, deranged nervous systems.
~b. Symptoms of contagious and infectious diseases;
prevention of transmission through use of indi-
vidual articles at feeding, in dressing, etc. ; quaran-
tines, etc.
5. Instruction regarding helpful books
II. Board of Health Agents (not analyzed)
III. For future and present parents: Practically all of the
above with elaboration of topics of education to give
an outlook for future. (Unless this is treated else-
where; the paper assigned points definitely to the
physical saving of child, perhaps there is a reason for
narrowing it to this one point. The wife of the doc-
tor is the one who was in training for nursing; she
maintains that both doctors and nurses make too lit-
tle allowances for individual differences in children
that make them respond differently to stimulation
physical or psychical.)
C. METHODS
1. Shaping courses in nature study (gardening, animal
care, physiology, and hygiene) and domestic economy to
present general basis for ideals and habits of wholesome,
simple, beautiful living. In the present general move-
ment in public schools from much to less formal and
276 CONTINUATION SCHOOLS OF HOME MAKING
routine work, from much to less second-hand experience,
from little to much first-hand experience in this already
begun movement changes can be naturally introduced.
2. Shaping courses in art and literature to bring out the
salient beauty and ethical elements of mother and father-
hood, of family life, of social living.
3. Since such shapings can come only through teachers who
are imbued with appreciation of their value and familiar
with their content, training schools for teachers must
remodel their courses.
4. The extension work of universities, the evening or con-
tinuation schools, the settlement house, the parents'
classes of the church (the Mormon Church works this
most systematically), the women's clubs, etc., can in
various places stimulate interest in and provide oppor-
tunities for acquiring knowledge. Dissemination of
carefully prepared literature would also be effective.
(North Yakima, Wash., issued to parents of the city,
five pamphlets helpful in "Education with reference to
sex.")
5. Boards or committees on the recreational life of the
communities should be established.
6. The specific courses for training of Mother's Helpers
should in method attempt much concrete work :
a. Examination of manikins and real babies for knowl-
edge of physical makeup of children.
ft. Practice in handling, bathing, dressing large sized
dolls, followed by same with real babies.
c. Preparation and study of diet with relative value and
need of prepared vs. natural food.
d. Nursery rooms visited and studied; care of them
learned through practice in demonstration room.
e. Experimentation with cultures to appreciate general
nature of bacterial life in relation to origin and
spread of disease.
/. Diaries of children under treatment for improvement.
Diaries of children making normal progress.
g. Diaries of activity of normal children during various
months of first year; same of subnormal for compar-
ison.
DISCUSSION 277
h. Apprenticeship or practice helping under super-
vision in interested homes, in day nurseries, hospitals,
asylums, etc., as opportunities are at hand. (Sort of
interne work.)
i. Eelation of employers and employees one of mutual
obligation and rights.
Concrete work supplemented by lectures, readings and dis-
cussions.
Mrs. Henrietta Calvin, Director of the Department of Home
Economics, State Agricultural College of Oregon: I am impressed
by the statement concerning the large number of women who
are now wage earners, and who will in a few years be the home
makers and the mothers. Statistics show that one out of
three of all girls of American parentage between the ages of
sixteen and twenty-four are wage earners. The next period
is from twenty-five to thirty-four years, when the percentage
lessens because they have dropped out to go into homes. These
wage-earning girls are many of them thought of as factory
girls. Some are in factories. Others are in homes. Some are
seamstresses, clerks in stores, clerks in offices, stenographers,
public school teachers. I sometimes fear that in the continua-
tion school you should admit that very valuable woman, the
common school teacher. She is often as grossly ignorant on
the subject of home making as any factory worker. The fac-
tory worker is one of those who exhibit the survival of the
fittest, which means in human affairs the survival of the
toughest very often. Her children will thrive under bad con-
ditions when the child of the common school teacher, who is of
a higher nervous type, will succumb. These women who have
spent from three months to three years in preparation for a
temporary occupation, will probably spend no time at all in
preparation for their life work; and we should emphatically
insist that some time before marriage, and if that is not pos-
sible then after marriage, they should prepare for taking the
responsibility and care of children. Those of us who have
been engaged in welfare movements find that often mothers
have been running private experiment stations to the detri-
ment of the first child. I don't know how we can get working
people who work during the day to study at night. We have
lectures in hospitals at night to nurses, and I find it difficult
to make them very teachable after a hard day's work. I won-
der if the Sunday school of the future might become a child
welfare school. There should be continuation schools of home
278 CONTINUATION SCHOOLS OF HOME MAKING
making not only for wage earners, but for college graduates
and university women. Many women who have gone through
a university and are familiar with the languages of other
lands have never learned the language of a child's cry. There
are women who can tell all the great thoroughfares followed
by Caesar's army, but who could not tell the thoroughfare
followed by microscopic invaders in their own body, nor how
to compete against an army of disease germs. Some care of
children should be taught to all women. It is most difficult
of all to teach unless we make women realize the value of their
own bodies and those of their children. Only then will a large
portion of this problem be solved.
Miss Louisa C. Idppitt, R. N., National School of Domestic Arts
and Sciences, Washington, D. C. : About two years ago in the
National School of Domestic Arts and Sciences I added by re-
quest, lectures on the baby to our course in personal hygiene,
first aid and the care of the sick in the home. We now have a
course of thirty lectures which we call child study. It covers
the care of one's health as a future mother ; the choice of the
future father as it affects the well-being of one's children ; the
effect on children of the mother's habits and conduct. A little
of eugenics is taught, modern social work for protecting babies,
vital statistics in these lines, prenatal influences, and influ-
ences of environment. They are taught why mothers should
nurse their babies; how to feed artificially when that is not
possible; the harm of soothing syrups and the avoidance of
dosing; also the essentials of contagious diseases, use of dis-
infectants, when to send for the doctor; how to give simple
treatments; care of ears, eyes, throat; the harm of enlarged
tonsils and of adenoids. Last year we borrowed a baby and
bathed it before the class. As a trained nurse I have seen
babies die because mothers did not know how to care for them,
and I am c<$nvinced every young woman should have this in-
struction. They have been exceedingly interested, ask a great
many questions, and would like to have each lecture longer
than the half hour in which it has to be given.
Dr. A. C. True, Director of Experiment Stations, Department of
Agriculture : I have been interested for a number of years in
the development of a proper system of education for country
people. In recent years I have had a little to do with efforts
to extend this education out beyond the college and schools
to the masses of people who live in the country. We recognize
that we must make this system of education cover not merely
DISCUSSION 279
the questions of agricultural production, but all the matters
that relate to the economic and social conditions of country
life.
One of the important elements of such a system of education
is the education of the women to be good home makers. Efforts
that are being made by the Department of Agriculture, by the
agricultural colleges and other agencies for the promotion of
agriculture and agricultural education in this country include
this subject. We have already built up a large extension sys-
tem along agricultural lines. That has been done so far in a
broad way, principally through the issuing of publications
and the holding of farmers' institutes. In recent years we
have included quite a number of publications relating to home
making. We have also begun to organize special institutes
for women. Last year several hundred of such institutes were
held in this country, attended by at least 150,000 women. This
is only a beginning. It is only the propaganda stage of that
part of this movement which relates directly to the home and
its interests.
In connection with the farm demonstration work carried on
by the Bureau of Plant Industry in cooperation with the agri-
cultural colleges and the General Education Board, canning
clubs for girls have been widely organized. These have at-
tained some commercial importance, several million cans of
vegetables having been sold last year. But their greatest
value has been shown in the arousing of interest in home and
school improvement among the women in the communities
where the clubs exist.
There is now a movement to complete this extension system
by bringing in what are called county agents or advisers
throughout the United States to establish local centers for the
dissemination of information for the benefit of the people liv-
ing in the country. Something has been done along this line.
I think there are now over 200 counties which have these
agents. Leaders now recognize definitely that it is vital that
this extension movement reach the masses of the women, as
well as the men living in the country. The local organization
must be the agent to accomplish this, and the women thus far
have been interested. They can be of invaluable help.
There must be a distinct effort to form some kind of local
organization to promote this extension system for country
people. Theoretically it would be very desirable if the country
schools could be made the centers for this work. But practi-
cally it is not likely that they will be efficient agents along this
line until we have changed the system of organization of these
280 CONTINUATION SCHOOLS OF HOME MAKING
schools. Those who have studied this problem most thoroughly
believe that we must go along the line of consolidation of the
schools. There again the women, through their organizations,
especially in those states where they are coming into political
influence should exert themselves to make a radical reform
In the organization of country schools. When we have a con-
solidated country school, we have approximated the conditions
that exist in our cities. We can then hope to have some sub-
stantial and effective system of continuation school, and the
consolidated schools can be made really helpful agencies for
the propagation of the methods of continuation work for the
masses of the women of the country along the lines in which
this Association is specially interested, as indicated by this
section program.
But while we are waiting for that consolidation of schools
in large numbers, we should make special effort to secure local
organizations in as many communities as possible. Just now
Lt happens that the office with which I am connected in the
Department of Agriculture is making an experiment with ref-
erence to the utilization in the country communities of what-
ever talent there may be that can be employed to make organi-
zations for educational purposes outside of the school. The
idea is to try whether it is feasible to find in any country dis-
trict a person sufficiently intelligent to take a simple course of
instruction prepared by an expert, gather about him or her a
group of fifteen or twenty people and carry out that course
of elementary exercises. That work is to be under the general
supervision of experts at the agricultural colleges. We have
now organized in the state of Pennsylvania two groups of
people on that basis. One is a group of men and the other a
group of women. We are giving those women a course in the
cooking of vegetables in the home.
We will do all we can to carry on in definite ways propa-
ganda along these lines. It is an enormous task, and we are
working under conditions very different from those in Europe.
We can therefore only learn in a general way from the Euro-
pean examples. But I think we shall ultimately build up,
under the leadership of such women as have spoken to us here
tonight, an effective system in home training for all the women
of our country, in the cities and in the country as well.
Miss Caroline L. Hunt, Expert in Nutrition, Office of Experi-
ment Stations, Washington, D. C. : I find myself agreeing with
almost everything that has been said, and yet I wish that there
had been a little more emphasis upon the opportunities offered
DISCUSSION 281
in general education for meeting this great need which we have
been discussing. I refer not only to the formal education of
the schools, but also to that informal education in sanitation
and hygiene for which our Chairman has done such valuable
work. If our schoolhouses could be built, equipped and cared
for as Dr. Putnam would like to have them, we might hope
that the pupils who go out from our elementary schools would
almost instinctively follow practices which we desire to see
adopted by mothers in their care of children. If young people
are to be trained as they should be, to have a feeling of cleanli-
ness and to apply the principles of sanitation in their daily
lives, we must have smaller classes and our schools must be
more like well-kept private homes. The better we can make
our general schools, the more likely we shall be to send the
pupils out to meet the demands that will be made upon them.
This has a special significance in the case of girls. The longer
we can keep a girl in school and the more opportunities we can
give her for general culture, the more likely she will be to rec-
ognize her own need of preparation for the responsibilities of
motherhood.
This brings us to the second great need in education, that of
thorough professional courses in housekeeping and in the care
of children. These two matters work together. Keep a girl
in school until she knows enough to recognize her need of
special training and then give her the chance to get this special
training.
The only point which has been brought up, about which I
have any doubt, is the compulsory education in the care of
babies and children and other home duties. The trouble is
that such compulsory training may interfere with other train-
ing which the girl may need. Girls and boys are permitted in
many places to start on their wage-earning career at the age
of fourteen years. This should not be, and we are gradually
lengthening the period of compulsory education, and also are
offering opportunities in the continuation schools to boys and
to girls. I question whether we have a right to compel a girl
to take any special course in a continuation school, any more
than we have a right to compel a boy to take a special course.
It the girl is compelled to study the arts of home making, while
the boy is taking courses which will help him to advance in his
career as a wage earner, the girl is necessarily handicapped.
My hope lies in the two points which I have emphasized the
extension of the period of compulsory education and the estab-
lishment of professional schools where girls will have an oppor-
282 CONTINUATION SCHOOLS OF HOME MAKING
tunity, if they wish, to study housekeeping and the care of
children.
Prof. Marlatt (closing discussion) : The points brought out
by Dr. True are exceedingly important on the general subject
of training women. The work that has been done at our com-
munity institute at Wisconsin University has been done largely
by physicians who go to the cities where there are no colleges,
and give lectures and demonstrations on the care of the sick
and of infants. In one Western State they have their hygiene
institutes where they teach for health rather than for care of
the sick.
Referring to some of the points brought out by Miss Hunt,
I think that in our present educational system we are so re-
organizing the public school that there will be an intermediate
period, called in some places the junior high school. It will
include the last grammar grade and the first and second year
of high school. In this way some high school work will be
put in the lower grades and thus much better and more inter-
esting instruction will be given in the seventh and eighth
grades. This is being done extensivley in the Western States,
and is the coming form of education undoubtedly. In this
way we will he able to reach children who usually drop out
of the seventh and eighth grades. It gives opportunity for
special teachers to work in these junior high schools. They
will be able to give an excellent elementary course in biology
in which we can conduct boys and girls at this formative
period into a knowledge of themselves and their responsibili-
ties.
SUNDAY SESSION
November 16, 1913, S P. M.
ADDRESS
INFANT WELFARE AND THE COMMUNITY
MiARY SHERWOOD, M. D., Baltimore
It is interesting to live in a great era such as the present,
which has witnessed the discovery of the value of the baby to
the community. Statisticians have given us figures to show
the relation of birth-rate to death-rate, and to prove that the
number of babies who survive birth and grow up are an impor-
tant concern to every community. Humanitarians and con-
servationists have made their plea that babies whose lives can
possibly be saved should not be permitted to die. It is surely
fitting that our association should be the vanguard of the great
Conservation Congress that is to meet in this city this week,
for no problem in conservation is so important as ours. 'No
other form of material wealth is as valuable as an adequate
number of healthy babies, strong by heritage, suitably cared
for at birth and intelligently reared to maturity.
PREVENTABLE INFANT MORTALITY
Our association showed a little courage in adopting as its
title "American Association for Study and Prevention of In-
fant Mortality." The very name implies that there is such a
thing as preventable infant mortality, and any community
which faces this fact stands condemned if it is not doing every-
thing in its power to prevent this mortality. "To look an evil
fairly in the face is to begin to conquer it." A time will come
when such an association as this need no longer exist because
all preventable infant mortality shall have been prevented.
MUTUALITY IN LIVING
No community is stronger than its weakest point. We have
lived through the era of egotism and have come upon the era
of altruism when we answer the question "Am I my brother's
keeper?" in the affirmative, and realize our responsibility to
our neighbor. A father and mother are naturally interested
in their own baby. But when every father and every mother
feels that every baby has a share in their sense of responsibility
we shall have the highest ideal of community life.
283
284 INFANT WELFARE AND THE COMMUNITY
RESPONSIBILITY OF THE COMMUNITY
We are an association for the study as well as the preven-
tion of infant mortality. Our problem is far-reaching. The
causes of infant mortality extend into the social conditions
and the political life of a community. Insanitary housing
conditions, bad drainage, insufficient ventilation, dirty milk,
flies all are contributing causes to a high infant death rate.
Filthy conditions in streets and markets, and the handling and
storing of food have both a direct and indirect bearing on our
problem. High temperature is conceded to be a causative fac-
tor in infant mortality. We go on refrigerating provisions on
an immense scale and at enormous expense, yet in only a few
hospitals have cooling rooms been provided for sick babies. It
has not yet occurred to us that it might be a public duty to
provide refrigerating rooms on a large scale where babies could
be kept well in the heat of summer.
Archaic methods of production and transportation of milk
still persist in many rural communities. We take hold of this
problem by the wrong end. We pasteurize impure milk, kill
the microbes and use the resulting mixture of milk and dead
microbes as food. Some day we shall insist upon the clean
production of milk. Every community has the power to change
these and other imperfect conditions of living.
SPECIAL TRAINING IN PEDIATRICS
Special knowledge is needed by physicians to enable them
to care properly for sick babies. I was never more strongly
convinced of this need than in talking recently with a nurse
who was handicapped by the fact that the physician attending
a sick child under her care had not had special training in
pediatrics. The nurse knew more about the case than the doc-
tor, yet she had to follow his directions. We can all unite in
the demand that medical students receive training in pedia-
trics. Sweden made this obligatory thirty years ago and now
has the lowest death rate among children of all the countries
in the world.
TRAINING FOR PARENTHOOD
We need educational standards for parenthood. Very in-
teresting work is being done by a section of our association
on Continuation Schools embodying the idea that girls and
boys should be trained for their responsibility as potential
parents and home makers. An intelligent people should surely
provide education for the most important business in life.
MARY SHERWOOD M. D. 285
ECONOMIC CONDITIONS AFFECTING INFANT MORTALITY
Various economic considerations affect the infant mortality
rate, such as the wages of the father and his ability to care
for a family, and the fact that many mothers are compelled to
be wage earners and therefore cannot nurse their babies. Very
few industrial establishments provide free rest rooms for work-
ing mothers where their babies can be brought at stated times
to be nursed. We have not fully studied the consequences of
permitting little girls to work long hours and to sacrifice their
vitality in hard work when these same little girls are the poten-
tial mothers of future generations.
BETTER OBSTETRICAL TEACHING AND PRACTICE
No greater problem is facing us for solution than the in-
struction of the prospective mother and her care in confine-
ment. "Time is slowly making ancient good uncouth" and
humanity is beginning to realize that modern scientific knowl-
edge no longer countenances the grade of obstetrical practice
which has come down to us from the time of Moses. You will
be shocked to hear that in our American rural communities
and our large cities from thirty to fifty per cent of confine-
ments are conducted by midwives. We are permitting abso-
lutely ignorant women to undertake a kind of care which re-
quires the highest degree of specialized knowledge of surgery,
medicine, obstetrics and sanitation. Many of our medical
schools are not prepared to teach obstetrics properly. No more
important subject could be had for study in women's clubs
and federations than the study of the facts of obstetrical teach-
ing and practice in America.
THE COMMUNITY
Every community should have a knowledge of the facts of
infant mortality. Every community should start some form
of baby-saving work. No work can be begun with greater as-
surance of success, for it is work for the future as well as the
present. As members of a community working for the wel-
fare of every baby in the community we shall begin to see the
realization of that great word: "He that is least among you
shall be greatest."
ADDRESS
WM. C. WOODWARD, M, D., Washington, D. C.
A few years ago when this Association was formed, the fact
that stood out prominently before the community was the
existence of an enormously high infant death rate. In keeping
with its object and purposes the Association was christened
the American Association for Study and Prevention of Infant
Mortality.
This seems to me to be a rather unfortunate name. When
we study "infant mortality" we fail often to see the dead baby
and the bereaved home. We stand back of that high-sounding
term and leave the prevention of infant mortality to those who
are charged officially with public duties, rather than go our-
selves to the homes of the ignorant and the poor to teach
them how to save their babies.
There are very few of us who do not love "babies ;" in fact
any one who does not love a "baby" would be ashamed to admit
it. But when it comes to loving an "infant," that is quite
another matter. You may have noticed that in the preceding
address the speaker did not once refer to an infant. It was
always the baby. It is the babies we want to save.
Unfortunately this conception of infant mortality has ob-
structed the larger vision of infant life. Death is a very strik-
ing phenomenon. It inspires every one with a sense of peril,
grief, and bereavement, and makes an impression that we can-
not get away from. Yet in its last analysis death is merely
one phenomenon in the life process, and in many ways it is not
a very important phenomenon to the individual chiefly con-
cerned. So we are not now endeavoring only to prevent infant
mortality; that is, of course, an incident in our work. But
what we are rather trying to do is to make the baby a well,
strong, happy baby; to carry that baby through infancy, and
pass him along into childhood with the best possible chances
for growing up to be an efficient man or woman.
I think we may possibly criticise the position that has been
taken in the campaign for welfare of infants. We have ap-
pealed too much to the community and too little to the indi-
vidual. In all of our work we have represented the baby as a
valuable asset of the community, and we have left it to the
community to care for that asset. Sometimes, along with the
286
W. C. WOODWARD; M. D. 287
emphasis we have placed upon the value of the baby to the
community, we have emphasized the responsibility of the par-
ents. We have shown how the parents must bear the burden
of bringing a sound, healthy child into the world and of caring
for that child until adult life. And the emphasis we have laid
upon the bare responsibilities of the parents, without any cor-
relating emphasis upon the value of the child to them, has
probably been a strong contributing factor toward lowering
the birth rate. We preach against race suicide, and some be-
lieve that voluntary childlessness is an evil under all condi-
tions. But certainly when we preach day and night, year in
and year out, the responsibilities of the parents for their chil-
dren without at the same time touching on the value of the
child to them, we discourage men and women from assuming
the burdens of parenthood.
We should preach more the value of the child to the parents ;
not in dollars and cents, of course, for no one would undertake
to measure the value of a child to its parents in that way. We
must emphasize more the factor referred to by the preceding
speaker, that is, the psychological and spiritual value of par-
enthood. Is the baby worth nothing in the home? Is it worth
nothing to the parents? Is it worth nothing to the brothers
and sisters? Certainly no one will admit that. It fills a place
in the life of every human being. We find that yearning on
the part of men and women for something to love, something
that cannot be measured in dollars and cents, something that
is often supplied in a vicarious way by the adoption of pets
and other things relatively useless, when the love and affection
lavished on them might be bestowed on some human being and
expanded in a more useful way.
The problem of infant mortality is an individual problem.
The state cannot assume it. The city cannot assume it. The
church cannot assume it. We have to come right down to the
individual, down to the man and the woman, the mother and
the father of the little child. We have missed, I think, one
of our greatest opportunities for the accomplishment of this
end in our failure, passibly through our inability, to use our
religious organizations. Nowhere, it seems to me, can we make
a more direct and a more powerful appeal to the best that
there is in the human race, and nowhere can we better inspire
the individual, than through the churches. If we can induce
the churches in some way to give particular attention to this
problem of baby health, this problem of sociology, this problem
I might say also of spirituality, we will have gone a long way
288 ADDRESS
toward solving it. If every church in this city and in the land,
would during the next year save one or two babies we would
have a very material lessening of the death rate, and in the
amount of illness. I plead, therefore, for an organized effort
on the part of the churches to cooperate with this Association
to the end that we may have a happier, healthier babyhood,
childhood, manhood and womanhood.
ADDRESS
THE CLAIM OF THE BABY
J. H. MASON KNOX, JR., M. D., Baltimore
Those of you who heard Dr. Holt on Friday evening will
remember that he spoke of the great attention paid in Ger-
many and in France to this problem of baby saving. This is
largely because of the diminution of the population and the
fear of statesmen that the armies will be depleted and that
other walks of life requiring men and women will not be suf-
ficiently filled. When we approach the question in a place
like this, we have a stronger lead. The plea to the Christ-
ian church is a great deal stronger than that. Certainly no
lesson of the New Testament is more evident than the value
of human life, and no fact in the life of Christ is more certain
than His care for infants. No lesson is more specific than His
new definition of the word "neighbor," namely, that we are
neighbors to those who are in need. The parable of the Good
Samaritan fits this effort to affect the reduction of infant mor-
tality precisely. No class of living persons can make such an
appeal to your sympathies and to your help, financial, per-
sonal, and of every other kind, as does an infant. He is abso-
lutely helpless, absolutely dependent upon his environment for
his very existence, to say nothing of his well-being. We can-
not be followers of the Master, we cannot even be good citizens
or good financiers, to put it on the lowest point of view, unless
we give the infant a better chance for life and for health.
So I say the infant has a legitimate basis for appeal to you
and all of us to know something of how his life can be con-
served. We estimate that 200,000 infants die every year in this
country out of an infant population of 1,500,000, and that
at least one-half of that death rate is unnecessary; that with
ordinary care approximately 100,000 human lives could be
saved annually.
What has the baby a right to claim from you and from every
community? First of all he has the right to be counted. That
is a very simple thing. Every livestock breeder counts the
young of his stock. Yet only lately have we come to think of
this thing. Only a little more than half of our country belongs
to what we call the registration area and counts deaths. A
still smaller proportion registers births. Only when we know
how many infants there are born can we know what propor-
289
290 THE CLAIM OP THE BABY
tion die from this cause and that. We are the only civilized
country in the world whose registration statistics are prac-
tically thrown into the waste baskets by the statisticians. Yet
the infant has a fundamental right as an American citizen
to be counted.
Second. The infant has a right to be healthfully born. In
raising livestock healthy animals are bred to produce healthy
young. Shall not our infants have the same advantage? This
implies first, healthy parents. It follows that no one should
be allowed to marry who is infected with any of those dis-
eases which can be transmitted to the offspring. The least
that healthy men and women thinking of matrimony can do
as a duty to the state, is to present proper certificates from
suitable sources that they are without transmissible disease.
In this way we could gradually stamp out these dreadful
scourges and stop this great loss of life which is so well known
in every medical clinic, and which we can attribute to the dis-
eases and crimes of parents. The helpless infant, if he could
voice his claim, would say, "I claim it as my right to be health-
fully born."
Third. The infant has a right to be born of a rested mother.
More than half of the infant population in this world is
brought into existence by overtired mothers, some working
up to the last minute before confinement. Statistics show
that the average weight of these infants is less, and their
vitality less, than if the mothers were properly rested. If
mothers have had adequate rest for two or three weeks before
their children are born, these infants have an average weight
of approximately seven pounds. If the mothers work up to
within one week of childbirth, the average weight would be
approximately six and a half and six pounds. This waste
occurs not only in the rural districts and among the ignorant
classes, but in New England and other states in the factory
towns where women spend a large part of their time in the
factories. I am thankful to say that homes have been started
to afford rest to these mothers at the right time before and after
labor. It is necessary to supply more adequate means so
they can afford to cease from their hard work at this critical
period in their lives.
Fourth. The baby has a right to be born properly. That's
the old story with which you are all familiar the obstetrical
problem. What a crime it is that at this important crisis
when two lives are in the balance, people without ability
should be allowed to jeopardize these two lives! Obstetrical
training is given much less attention than other branches of
J. H. MASON KNOX, JR., M. D. 291
the medical profession. Men are graduated from medical
schools without even having conducted their first case of
labor. Much of this work is conducted bj ignorant women.
Do you see how slothful we are?
Fifth. The baby has a fundamental right to be reared
healthfully. This includes, first, his right to be breastfed.
How many are deprived of this right! There is no satis-
factory substitute for mothers' milk. It is almost as important
that the baby should have its mother's milk as it is that he
should be connected with the mother before birth. How
many physicians advise weaning unnecessarily upon the
slightest digestive disturbance, taking it as an indication that
the mother's milk does not agree with the child, when in
nearly every case with a little patience during a period of
uncertainty, and some care on part of the physician and co-
operation on part of the mother, the trouble will vanish and
the nourishment will agree with the child. We find many
working women willing and anxious and able to nurse their
babies. Of nearly six hundred delivered at the Johns Hop-
kins Obstetrical Clinic, over sixty per cent were able to nurse
their babies for at least six months. Here you have pure
warm milk in just the right quantity. Let us make a plea
in this campaign for breast feeding, for the natural nourish-
ment of every baby.
There are reasons why some mothers cannot nurse. If this
catastrophe takes place, the least we can do is- to pro-
vide the very best substitute, and that is pure cow's milk
properly modified, given at the right intervals and in the
right quantity. There is no other substitute which is mod-
erately satisfactory. It is expensive and requires intelli-
gence on the part of the mother and conscientious coopera-
tion and skill on part of the physician. But these things ought
to be at hand when the stake is so high. It ought to be con-
sidered a crime for a mother to have to go around the corner
and buy poison, which is called milk. A large part of the
mortality which takes place in the summer is due to impure
milk. Let us bring this knowledge home to the mothers and
give them the opportunity to buy something which is really
clean food.
The baby to be healthfully reared must be properly clothed,
and that means more than most people think. A friend of
mine was called a short time ago to attend a child thought
to be dying. It seemed not to be breathing, and it was blue and
cold. The physician undressed the child, taking off layer
after layer of very tightly wrapped clothing. Finally, as the
292 THE CLAIM OF THE BABY
child's chest was exposed it began to breathe, and soon the
natural color returned. That mother was most anxious and
loved her baby. She didn't know she was keeping him too
warm and too tightly wrapped.
In the last analysis, two things ought to be emphasized. In
the first place we cannot get along with foster-mothers only.
The real mother is the pivotal point. The mother must be
taught. Almost without exception she admits the visiting
nurse to her home with gratitude, and cooperates up to the
limit of her ability when she is shown in a tactful way. We
have an opportunity here which perhaps no other propaganda
has, namely, of appealing to the natural instinct for the co-
operation we want. I believe all these milk stations, many
babies' hospitals and dispensaries, important as they are, are
chiefly needed to fill in the interval while this maternal
ignorance exists and while thousands of babies are being born
amid unhealthful surroundings. The time must come if we
see our duty and perform it, when every girl growing into
maidenhood and motherhood shall realize that it is important
and proper to know something of the care of babies. If she is
to bear children she shall demand the best obstetrical care;
that she and her husband shall be free from disease; that she
shall be rested before labor and shall claim the privilege of
nursing her own baby; if she cannot then it shall have only
the best cow's milk procurable. If she cannot get it herself
she should see to it that the state or some philanthropic insti-
tution supplies it. Then there will come the time when in-
stead of losing 200,000 babies we will save at least one-half
of that number. The difference between the death rate in
China and in New Zealand is striking. One country has a
death rate of over 300 per 1,000 and the other a death rate of
60. The situation in Baltimore is very similar to that of
Washington. We have a peculiar problem in both cities in
our colored populations, whose death rate is more than double
that of the white children. For our own self-preservation we
must take better care of our colored population. They spread
disease among the white people. We do not begin to take
care of them as they were taken care of in slavery. Then
they were considered as children and were cared for properly.
For good political reasons they have been made free, but they
have been permitted to fight it out themselves and they do not
know how. So, I look to Washington and to Baltimore to
lead the way in the real emancipation of this race.
SESSION ON VITAL AND SOCIAL
STATISTICS
Monday, November 17th, 10 A. M.
COMMITTEE
CHAIRMAN
MISS JULIA C. LATHROP, Washington, D. C.
ACTING CHAIRMAN
DR. GEORGE Ml KOBER, Washington, D. C.
SECRETARY
MR. LEWIS MERIAM, Washington, . C.
DR. S. J. CRUMBINE, Topeka, Kansas
DR. MARIA M. DEAN, Helena, Mont.
DR. W. L. HEIZER, Frankfort, Ky.
MRS. PERCY V. PENNYPACKER, Austin, Texas
MR. SHERMAN C. KINGSLEY, Chicago
PROF. W ALTER F, WILLCOX, Ithaca, N. Y.
STATEMENT BY DR. KOBER:
We greatly regret the absence of our Chairman, Miss Julia
C. Lathrop, who is prevented from being with us on account
of serious illness. It is gratifying, however, to know that she
is making a good recovery, and we hope she will be speedily
restored to her great and useful work.
The program this morning is on vital and social statistics.
Social statistics are of the greatest importance in determining
the causes of excessive infant mortality. It is perhaps not
sufficient alone to establish the birth of a child in order to
secure the rights of future citizenship, but also to know under
what conditions the child was born; whether he is a child of
the less resourceful people who are compelled to live in one or
two rooms of a tenement house, or whether he is one who
belongs to the more fortunate class. Washington, in the Dis-
trict of Columbia, in 1900, led all other cities in an excessive
infant mortality. Our rate was 274 per thousand population,
under one year of age. This was due to the excessive death
rate among the colored population, the proportion of deaths
being 2 to 1 what it is among the white, due largely to socio-
logical conditions. Our colored people constitute our labor-
ing class to a large extent. They are exposed to hardships and
privation of every kind. It is gratifying to report a reduc-
tion of more than one-half in the total infant mortality in the
last few years, the colored population sharing in the reduction.
I have great pleasure in introducing Dr. W. C. Woodward,
the Health Officer.
293
THE USE OF VITAL STATISTICS FOR THE CONSERVATION
OF INFANT LIFE
WILLIAM C. WOODWARD, M. D., LL. M., Health Officer of the
District of Columbia
Along with a lessening of the birth rate in all civilized coun-
tries has come, as the very name of this association indicates,
a demand for the prevention of infant mortality, to the end
that there might be no avoidable diminution in the rate of
natural increase in population. Death stands out as a cruel
fact in the experience of everyone and it was perhaps nat-
ural, therefore, that attention should have centered first on
the prevention of death rather than on the prevention of disease.
That it did so center was none the less unfortunate, since the
demand for the prevention of mortality has served to obscure
the real purpose of the movement, the conservation of life not
alone in numbers but also in fulness or efficiency. Our aim is
not merely to postpone death until after infancy, so that infant
mortality may be reduced, but also to develop the happiest
and healthiest infant possible, so that he may pass out of
infancy into childhood with the best outlook for the future
that human knowledge and love can procure for him.
DEFINITIONS
Infant mortality has come by common consent to mean
mortality during the first year of extra-uterine life. Any
study, however, having in view the conservation of infant life
must extend over a considerable period preceding birth, so
as to discover how prenatal circumstances have influenced
and may influence the subsequent extra-uterine life of the child.
And any such study must be carried from infancy on into
at least the beginning of childhood, so as to disclose the condi-
tions, good and bad, that appear in childhood as the result
of causes operating during infancy, so that we may promote
the operation of such conditions as are favorable and retard
or eliminate such, as are bad.
The term "vital statistics" is popularly understood as cover-
ing only such figures as relate directly to births, illness, and
deaths. In the professional work of the sanitarian, however,
it must be accepted as comprising all statistics relating di-
rectly or indirectly to biologic processes of the human race.
294
W. C. WOODWARD, M. D. 295
Used in this sense, the term includes many data pertaining to
community life, or sociologic statistics, and some pertaining
to the natural physical environment, or meteorologic and geol-
ogic conditions, in so far as they may be correlated with the
biology of man.
In this paper, the word "births" is to be understood as
including both live births and stillbirths unless otherwise
stated, or otherwise indicated by the context.
THE EELATION OF VITAL STATISTICS TO THE STUDY OF INFANT
LIFE
Notwithstanding the brevity of the period covered by the
term infancy, the life of the infant is no less complex than
the life of the adult. In infancy, senility does not concern us,
but premature birth does. Typhoid fever is rare, but diarrheas
of obscure origin are exceedingly common. Occupational dis-
eases are unknown, but hard labor on the part of the mother
during pregnancy may react unfavorably on the offspring.
And diet, air, clothing, sleep, and even nerve strain go to
determine the health of the infant quite as much as they go
to determine the health of the adult. Until infant life has
been resolved into the ultimate elements of which it is com-
posed, and these elements thoroughly studied singly and in
groups, we can have no proper understanding of it. Preven-
tive measures necessary to avert premature delivery and its
consequences will not suffice to prevent death from diarrheas;
but if excessive morbidity and mortality are due to diarrhea,
prenatal nursing is not the remedy demanded by the situation.
The measures that are effective against diarrhea will not di-
minish fatalities from pneumonia, and if an unduly high death
rate is due to the prevalence of the former disease, methods
for the prevention of the latter are of no avail. And it is only
by the use of vital statistics that we can resolve infant life
into its primary elements and determine the relations of each
to the others, so as to find out what had best be done for the
welfare of the babies in the community. The statistics needed
for this purpose are: (1) Statistics of birth; (2) Statistics
of illness; (3) Statistics of death; (4) Sociologic data; (5)
Data relating to weather conditions.
STATISTICS OF BIETHS
Until the number of infants in the community during each
period and place under consideration has been ascertained,
there is no sound basis upon which to measure the prevalence
of illness and death. If 1,000 infants are present during
296 VITAL AND SOCIAL STATISTICS
twelve months and 100 deaths occur, the record is good, ac-
cording to present standards; but if only 500 children are
present and the same number of deaths occur, the situation
calls for careful investigation.
For the determination of the number and the types of in-
fants present, nothing can take the place of an accurate regis-
tration of births. Even an actual enumeration of the infants
in the community is not sufficient; for an enumeration ordi-
narily shows merely the number of infants present at the very
time the enumeration is made, while the basis required for
the study of infant illness and death is the number of infants
exposed to such events during the entire period under con
sideration, and this is the number born during that entire
period and not merely the number present during a part of it.
Moreover, any attempt to enumerate at the end of the year
by house to house visitation all infants who have been in the
community during the preceding twelve -months is not only
certain to yield inaccurate results, but such results as it does
yield come too late to afford the basis for direct measures to
safeguard infant lives. Not only does the registration of
births afford the only proper method of obtaining accurate
information as to the number of infants exposed during any
given period to illness and death, but it affords the only
means for determining the kinds of infants who are so ex-
posed; for determining, for instance, the sex of the infants,
ages of parents, number of children born previously to the
same mother, and so on. And what is quite as important,
the registration of births is the only way of obtaining prompt
information concerning such births as occur; and promptness
is a first requisite for preventive work.
To obtain an accurate record of births requires in the
first place an enforceable law and in the second place some
one to enforce it. Keturns of stillbirths, at least such as occur
in the latter part of pregnancy, can be made fairly complete
by the method commonly used to obtain accurate returns of
deaths, namely, by requiring that a burial permit be issued
before the body is disposed of. Keturns /of births other than
stillbirths are not so -easily obtained, but they can be gotten
through the adoption of the following methods :
1. By systematically checking reported deaths of children
under any given age, say one year, with the record of births
and calling to account those persons, if any, found responsi-
ble for failing to report such births as are found unrecorded.
2. By systematically publishing the names of parents of
children whose births have been reported, thus affording par-
W. C. WOODWARD, M. D. 297
ents, and tlieir relatives and friends, opportunities of learning
through the local newspapers when a report has been made.
3. By sending to all the parents to whom a birth is re-
ported a certificate attesting the registration of the birth, thus
teaching such parents, and through them their relatives and
friends, to look for such a certificate after every such event.
4. By educating the public through timely articles in the
newspapers and in the bulletin of the Health Department, if
there be such a bulletin.
5. By having an inspector or inspectors investigate the
birth registration of such infants as he may be able to find on
the streets and in the parks, or to locate through other
methods, and if any births be found unreported, cautioning
the offenders, or prosecuting them if the circumstances call
for such action.
STATISTICS OF ILLNESS
One of the greatest drawbacks to the scientific study of
infant life is the absence of morbidity reports. Such reports
are now commonly limited to those relating to communicable
diseases, including ophthalmia neonatorum. A few cities
have required the reporting of diarrhea. No sanitary author-
ity, however, has today anything like a satisfactory system
of morbidity reports, and yet such reports are necessary for
any thorough-going study of disease, whether communicable
or not. Unless cases are reported, we can not know, except
as deaths occur, whether a given disease is or is not present;
and the presence or absence of a disease that does not of itself
cause death can not be known at all, except by chance. In
the absence of case reports it is impossible to learn when and
where a disease not ordinarily present first enters the com-
munity, and where, when, and how any disease spreads. Yet
all these facts must be known before we can efficiently and
economically wage war against the malady. If the fatalities
from a disease amount say to ten per cent of the cases, and
only fatal cases be reported, then the disease producing condi-
tions may have resulted in ten cases, and these ten cases may
have run their course and other cases be in progress, before
even one death is reported; and before deaths have been re-
ported in sufficient number to give rise to suspicion that the
disease is unduly prevalent, an outbreak may be well under
way.
Under any circumstances, since the severity of even the
same disease varies from time to time, the number of deaths
alone does not afford a satisfactory index even to the extent of
298 VITAL AND SOCIAL STATISTICS
prevalence, to say nothing of distribution and mode of spread-
ing. Moreover if a case is not reported until after death,
there is added difficulty in getting necessary clinical and
sociologic data pertaining to it. It is more difficult to ap-
proach the bereaved parents with any inquiry" concerning the
circumstances preceding the attack, since the inquiry may re-
veal as the immediate cause some act or omission on the part
of the parents, through neglect or ignorance; and, no matter
how willing they may be to give the desired information,
time and the emotional stress of bereavement may have oblit-
erated from their recollection essential facts, or have estab-
lished in their memories a faulty perspective, distorting the
relative importance of the preceding events. Then, too, facts
obtained concerning the fatal cases alone may not be sufficient,
and unless the percentage of fatalities is great, probably will
not be, to enable an investigator to focus upon any one condi-
tion, or upon any group of conditions, that he can hold respon-
sible for the occurrence of the disease. On the other hand,
if he be permitted to study the environment of each case as
soon as it is discovered, he will probably be able to find some
characteristic condition or conditions common to many cases,
and he may thus be enabled to determine the cause of the prev-
alence of the disease. It is, of course, unnecessary to point
out that if the conditions responsible for the prevalence of any
given malady be not located until after they have given rise
to enough fatal cases to lead to their detection, much valuable
time will have been lost for the removal of such conditions,
or in the issue of a warning against them if they be not re-
movable, and much unnecessary damage may have been done.
The fact that the causes of many diseases, even some of
the most common ones, are not known, can not be accepted
as proof that the reporting of cases of such diseases could not
lead to the discovery of the conditions operating to produce
them ; for if the cases of such diseases were reported, then due
inquiry might be promptly made, and especially with respect
to the diseases of infancy, all of which are more or less acute
when they first come under treatment, it is not impossible that
the causes might be discovered and means devised for their
removal. But even though the reporting of cases should not
lead to the discovery of the causes of any particular disease
and to their removal, yet such reports would enable the proper
authorities to provide relief for individual cases, whenever
they might be found in need of assistance.
It is not intended here to recommend that every case of
illness be reported to the sanitary authorities ; 'for it would
W. C. WOODWARD, M. D. 299
be impracticable continuously to investigate each and every
case; and unless some definite action follows a report, the
making of reports is likely to be seriously objected to, and
very justly so. What is needed, however, is the vesting of
sanitary authorities with power to require the reporting of
cases of any disease that such authority may be investi-
gating, and of every disease against which the sanitary author-
ity is prepared to take definite preventive action requiring a
knowledge of the existence and the location of the individual
cases. If it be desired to study the incidence and causes of
diarrhea, that disease should be made reportable so long
as the investigation is in progress. If the investigation dis-
closes measures that the sanitary authority can take for the
prevention of the disease and the adoption of those measures
requires a knowledge of the existence and location of each
case, then reports of diarrhea should be required at all time.
If it is desired to investigate in like manner the prevalence
of pneumonia, the same course should be followed. And so on.
In the absence of any method for procuring a record of
illness from the entire community, something may be learned
by the systematic use of the records of hospitals and dis-
pensaries. A record from day to day or from week to week
of all the infants admitted to the hospitals or presented for
treatment at the dispensaries would give at least an index to
the prevalence and distribution of disease in the community
and might afford a fair basis for at least a superficial investi-
gation.
STATISTICS OF DEATHS
Mortality reports are the chief stock in trade of the aver-
age student of infant mortality, and in many cases his only
stock. On the one hand, the gravity of death and its effect
on the family and friends of the deceased, and on the other
hand, the comfort and joy of convalescence, by contrast ob-
scure in the minds of the average thinker the seriousness
of the results that may be due to illness that does not termi-
nate in death. Then, too, it is comparatively easy to obtain
statistics of death, but by no means easy to obtain statistics
of illness that does not kill. The collection and compilation
of mortality statistics is, therefore, recognized generally as a
legitimate function of the government, although unfortunately
it is not always recognized, as it should be, as one of its
essential functions. All of these circumstances have given
to statistics of death in the mind of the average statistician
an exaggerated importance and value. As a matter of fact,
300 VITAL AND SOCIAL STATISTICS
however, each death registered must be looked upon merely
as an incident in a group of cases of illness and studied as
such.
In a city no difficulty is likely to arise in effecting a
complete registration of deaths, provided there is anything
resembling an effective registration law and any serious at-
tempt to enforce it. Let the law but provide that no dead
body shall be buried until after the issue of a burial permit
by the proper registration office and hold the undertaker and
the superintendent of the cemetery each personally responsi-
ble for any violation of it, and it will bring into the registra-
tion office a record of all deaths, if there is a competent officer
properly equipped with official machinery for its enforcement.
In sparsely settled places, however, difficulty arises. But even
in such places the registration of deaths can be effected by
the adoption of measures similar to those recommended for
bringing about the registration of births; by requiring all
vendors of coffins to report to the registration officer each
coffin sold by him, and details as to the proposed use of it;
and by imposing upon the clergyman who officiates at the
funeral and upon the person in charge of the burial ground,
as well as upon the physician in attendance during the last
illness, if there was one, the duty of seeing that the death is
reported; provided, of course, there is some competent official
responsible for the enforcement of the law. The method
adopted in Indiana, requiring the coroner to exhume every
dead body found to have been interred without a permit and
to hold an inquest over it, would presumably be effective,
especially where, as in Indiana, the coroner is entitled to col-
lect certain personal fees for the exhumation and inquest.
SOCIOLOGICAL DATA
It is well enough to know the number, location, and kind
of infants in the community in any given period of time; to
know the amount and kind of illness prevailing among them ;
and to know the number of deaths, and their causes. If we
know so much we can with more or less hope of success apply
to the situation such general remedies as are recommended in
text books on hygiene and in other ways. But there will be
no directness to our treatment of the situation, and no likeli-
hood that we will ever add materially to our knowledge con-
cerning the conditions causing infant mortality or concerning
the prevention of such conditions.
Every case of illness is due to the preponderance of hurt-
ful conditions over those that tend to conserve, and no study
W. C. WOODWARD, M. D. 301
of infant life can be complete which, does not include all con-
ditions, those that tend to save as well as those that tend to
destroy. The knowledge thus gained may point the way to-
ward the diminution of illness and death, either by stimulating
the development of favorable conditions or by eliminating
those that do harm, and the very inquiry will have an effective
educative influence upon the community. Unlike the statis-
tics of birth, illness, and death, however, data pertaining to
social conditions can be obtained only by paid workers, under
official direction and control. The data needed have reference
to heredity, to the size of the family and of the family income,
housing conditions, the employment of the mother, the per-
sonal history of the baby, and so on. A record must be kept of
general conditions within the community with respect to
food supply, water supply, waste disposal, the prevalence of
communicable diseases, the cost of living, and other similar
data having a possible bearing upon the causation of illness.
WEATHER STATISTICS
Formerly much time was devoted to the study of weather
conditions as related to disease, but subsequently, probabh
because of the barrenness of the inquiry and the growth of the
germ theory, there was a lessening in the attention paid to the
subject. More recently, however, at least in so far as relates
to mortality among infants, there is a tendency again to take
it up. Statistics pertaining to the weather may, therefore,
be classed among the vital statistics that must be available
in connection with the study of infant life. Such data must
cover temperature, humidity, rainfall, duration of sunlight,
and direction and velocity of wind. They must be recorded
so as to show with as much detail as possible such variations
as occur in each of these elements of the weather, and so as to
permit the study 'of them individually and in groups. And
finally, it must be possible for the investigator, at least until
the influence of weather conditions is better understood, to
correlate any one element, and any group of elements, with
individual cases of illness. Only by such analysis of individual
cases will it be possible to determine just what part the
weather plays in the occurrence and progress of disease.
METHODS OP STUDY
Probably the chief reason why the vital statistics of this
country are in such a deplorable condition is that until re-
cently they were applied to no practical end, and even now
there is a vast wealth of statistical material still unexplored.
302 VITAL AND SOCIAL STATISTICS
In the absence of any definite end toward which such statis-
tics were applied, it was naturally very difficult to interest
legislators and physicians in them, and unless some sub-
stantial use be made of the statistics that are now being col-
lected, it will be hard to maintain such interest as has been
aroused.
The collection and compilation of statistics is a very sim-
ple matter as compared with the determination of their mean-
ing. And until their meaning has been determined, statis-
tics are useless for all practical purposes, no matter how
great their potential value may be. The primary operation
toward the determination of the meaning of any statistics is
analysis into elementary groups and sub-groups. Thereafter,
by varying methods of synthesis and by comparison of these
groups and sub-groups with one another and with correspond-
ing groups and sub-groups from other sources, we seek to find
their meaning. The chief sources from which corresponding
groups and sub-groups are drawn for comparison are other
similar places during the same period of time, as City A with
City B, and the same place at other similar times, as City A
in 1912 with City A in 1913. For some purposes it will be nec-
essary to split into parts the primary geographical unit,
usually a state or a city, and the primary chronological unit,
usually a year, for the purpose of closer analysis and study.
Such conclusions as may be reached will be valuable in
proportion to the number and accuracy of the recorded obser-
vations upon which they are based. The variety of correlated
matters to which such observations relate tends to add to their
value, but with proper care conclusions of some value may
be reached with observations of limited scope, if they be suf-
ficiently numerous and accurate. It is, therefore, not neces-
sary to wait until statistics have been collected in relation
to population, births, illness, deaths, social conditions, and
the weather, before beginning analysis. Even if nothing more
than the number of deaths and their causes be known, then
by comparing the figures for one year with those of the next
preceding year, and so on back for a few years, and by determ-
ining variations in relative influence of different causes of
death from year to year, the local trend of mortality will be
learned. And the trend of mortality within the community
gives the very key to the action that is needed, even though
it may not show whether the prevalence is too great as com-
pared with other places.
Maps, charts and diagrams are invaluable aids to the analy-
sis and interpretation of statistics, especially when the work
DISCUSSION 303
is being done by more than one investigator, either coinci-
dently or consecutively. They increase, too, immeasurably the
practical value of the results of any statistical study, because
of the ease with which they may be understood by persons
who are without training with respect to public health mat-
ters ; for just in proportion as they can be understood by such
persons, they can be used for the education of the laity, in-
cluding those who must enact the health laws for the govern-
ment of the community and provide appropriations for their
enforcement.
CONCLUSION
To follow in its entirety the plan of investigation here
outlined would require an enlargement of authority and ap-
propriation over such as now ordinarily exist. In no other
way, however, are we likely to accomplish the end we seek.
The study of deaths alone will not accomplish it. The study
of sick babies in hospitals and dispensaries will not do so,
however much it may teach us as to treatment. To learn
how to prevent disease we must study not only dead babies
and sick babies but also well babies. We must study their
heredity and their daily life, and when they become ill we
must study them in relation to the very environment in which
they have been up to the time when illness occurred. In rela-
tion to the interests involved, the cost would certainly be no
greater than the cost of many another investigation undertaken
with possibly less worthy ends in view. And simply as a busi-
ness proposition such a study of infant life is necessary if
we are to know whether the energy and money we are spend-
ing for the conservation of infant life is producing the largest
and best results of which the expenditure is capable.
Humanity and sound public policy demand the conserva-
tion of infant life. Efficiency demands that records of work
done toward that end and of results accomplished be kept
and analyzed. And for any community to refuse to grant the
authority and funds necessary for such work is about as
wise as it would be for a merchant to refuse to employ a
competent bookkeeper, or for a corporation to try to get along
without a controller or an auditor.
DISCUSSION
Dr. Helen C. Putnam, Providence, K. I. : Will Dr. Woodward
please give a definition of stillbirth?
Dr. Woodward: I would not require a doctor to report a
stillbirth as such. The doctor ought to report as to whether
304 VITAL AND SOCIAL STATISTICS
the child's heart beat, or the child breathed or made any
voluntary movement after the extrusion of the body from the
mother. A child is said to be stillborn when, after the com-
plete extrusion of the body of the child from the body of the
mother, there is no evidence of life whatsoever. It may be
there is a gasp or a cry; it may be the child is silent, but
there is beating of the heart ; or it may be you cannot detect
respiration or circulation, but you can detect some other
muscular movement. If any of these things occur after the
extrusion, that is a live birth and should be registered, whether
the umbilical cord be cut or not. The cutting of the cord
makes no difference.
Dr. S. Josephine Baker, of New York: Dr. Woodward has
covered this subject so completely that it leaves very little
for the rest of us to say. Just one or two points occurred
to me as being practical in the utilization of vital statistics,
as the result of work we have been doing the last few years.
The birth record is perhaps the starting point of about
seventy-five per cent of our effective baby-saving work. Vital
statistics are of value only in so far as they are used. There
is little use in trying to maintain a birth registration for
purely academic reasons. Birth certificates are of value in
the survey of communities to determine not only the births,
but the most effective way to reach the new-born babies. In
order to achieve the best results it is essential to reach the
mother as soon as possible after the baby is born and the
birth certificate furnishes the easiest method of doing this.
In our attempts to reduce the death rate from congenital de-
bility the mother must be reached before the baby is born,
and as yet we have not devised any effective way of doing
this. I believe that the great majority of babies who die
during the first month of life could be saved if we could reach
the mothers early enough. Our present system of birth regis-
tration does not help us much in this regard. To be effective,
all births should be registered within forty-eight hours. There
are some communities that require registration within thirty-
six hours and some within two days, but from the reports
that I have received I believe that the law is not always ob-
served. Under the present system we use the information
contained on the birth returns in order that a nurse may be
sent at once to see the mother and put her in touch with the
various agencies that may be of service to her and at the same
time give her instruction in baby care. This method has been
found extremely valuable.
DISCUSSION 305
Morbidity statistics, in my opinion, are in many instances
of so doubtful a value that I am skeptical regarding them.
This is particularly true with the variation in diagnosis made
by different physicians. I had an experience about two years
ago which causes me to almost entirely discount the value of
the analysis we make of the various classes of diseases caus-
ing death. At that time the diarrheal mortality in New York
City showed a remarkable increase ; the total number of deaths
of infants was not any larger than it had been for the same
period a year before, but it was not the time of year when we
might expect gastro-intestinal diseases to occur with any fre-
quency. A decrease was noted in the deaths from so-called
"congenital" causes which exactly corresponded with the in-
crease in the deaths from the diarrheal diseases. An invest-
igation of this matter showed that this increase in diarrheal
diseases occurred exclusively in the institutions and a further
analysis showed that it was due to the death returns from
one foundling hospital. A conference was held and one of
the physicians of the institution in question stated that he
thought he knew the reason for this increase and would take
steps at once to have the matter changed. It seems that the
institution had a new house physician. He had been reading
the bulletin issued by the Federal Census Bureau relative to
the causes of death that would be accepted. This list states
that malnutrition would not be accepted as a cause of death.
New York, however, has always accepted this diagnosis, if
explained. The house physician, thereupon, began certifying
that gastro-enteritis was the cause of death in each instance,
entirely eliminating all of his marasmus cases and the other
so-called causes of congenital debility. As soon as he was
compelled to record the proper diagnosis on the death certifi-
cate the number of deaths from diarrheal diseases fell with
astonishing rapidity. The decrease was over fifty per cent
the first week after the man's attention was called to the
undesirability of his methods. I doubt if we can obtain under
our present system any accurate morbidity statistics and so, for
the present at least, we must depend upon our mortality sta-
tistics as the best basis we have for investigation. This can
be used in many ways and a record of infant mortality can
be kept from day to day, carefully expressed in chart form or
by so-called pin maps, so that whenever there is an increase
in any particular kind of disaese in any particular locality
an immediate investigation may be made of that area.
There is another point of view regarding statistics which
you may be gathering. In statistics which have for their
306 VITAL AND SOCIAL STATISTICS
basis answers given to questions, there is great danger in
assuming that deductions drawn from such statistics are true.
Four or five years ago I made a personal investigation of five
hundred deaths of babies under one year of age. I visited
each home and asked the mother the usual questions regard-
ing the care of the baby before its death. Invariably the
mothers were on the defensive, feeling that they were to be
blamed, so that, when I asked if the baby had been breast-fed,
they almost invariably said, "Yes, entirely so." If I asked if
the baby had been given water, they told me that it had,
every day. The inquiry as to whether it had been taken out
regularly and whether it had been bathed frequently was
most always answered in the affirmative. I then canvassed the
tenements to find five hundred well babies under one year of
age, and put the same questions to the mothers. In these
cases the well babies were usually playing on the floor in a
contented manner and the mothers had exactly the opposite
mental attitude to what I had encountered before. These
were rather boastful, so that when I asked as to the manner
of feeding I found a very low percentage where the baby was
fed entirely on the breast, but in a large number of instances
the mothers stated that they gave the baby any food that it
seemed to want. When I asked if they were taken out regu-
larly, the mothers said, "No, only when an opportunity pre-
sented itself." They said, in a large number of instances, that
they did not open their windows except when the weather
was good; that they gave the baby water only when they
thought of it. The only reasonable conclusion that could
be drawn from these two sets of figures was that the way
to kill a baby was to breast feed it, to keep it in a well-aired
room, to give it water and to take it out. So much for the
danger of depending upon this kind of information.
There is a further point, however, and that is that the
average record card of most of our cases is a record of opin-
ions and I want to warn against accepting statistics which
are based upon opinions and not upon facts. I do not be-
lieve that a visitor or nurse has a moral right to put down
upon a baby's record card the fact that the baby sleeps in a
well-ventilated room unless she has seen it do so, and that the
baby is breast-fed unless she knows from experience that this
is true, otherwise we are apt to be led astray by an immense
amount of statistical data which is not based upon facts.
There is one use of vital statistics which Dr. Woodward men-
tioned, and that is their value as a publicity weapon. I be-
lieve that four or five years ago it was an unusual thing for
DISCUSSION 307
a newspaper to publish vital statistics, but we have now
found out tliat they can be presented in such a way that the
newspapers will accept them and publish them and public
interest may thus be aroused. This is a very valuable method
to be used in any attempts to raise money for the support of
the work in which we are engaged.
The Chairman: We will be glad to hear from Dr. Holt.
Dr. L. Emmett Holt, New York: There are too many statis-
tics circulated that have for their main purpose inducing
people to give contributions to support the work. I have in
mind the report of a babies' welfare association as it is issued
every week in New York. They issue a report of so many
milk stations in operation, the number of children served, say
20,000; the mortality among the children coining to the milk
stations being about half of one per cent of the mortality of
the children treated in institutions. The conclusion to be
drawn from these statistics is that the only way children can
be saved is in that milk station. I think we might just as
well say that the mortality for the period among the well
children was half of one per cent and among the sick children
it was very much greater. As a matter of fact we have had
during the last year a considerable number of intestinal cases
referred to us from the milk stations. A large proportion
of those referred, died within twenty-four hours after they
were received. The inference is that the milk station kept the
children under observation until they saw they were likely
to die and then turned them over to the institution. These
statistics convey an erroneous impression and are injurious,
because we are all working for the one thing and that is to
save life. I am not criticizing the work of the milk stations,
but their way of using their figures.
I wonder if Dr. Woodward appreciates how extensively the
publication of names and addresses in birth registration may
be used by agents of patent food, men who distribute samples.
I don't see that such publication of birth registration is likely
to do much good. I can see some harm coming from it. It
may be useful in that it stimulates people to register. This
matter of statistics is very important and we are making
great progress. It is not necessary to discredit the work of
others who are doing a different kind of work. One must
make his report according to the material which he has. If
308 VITAL AND SOCIAL STATISTICS
the milk stations would follow up these children to death or to
the end of the season, and then credit the deaths to the milk
stations, a fair estimate of the results of work could then be
made.
I wish to enter a strong protest against the misuse or abuse
of statistics by financial agents or business secretaries whose
motive is not scientific but commercial. We should strive to
be honest not only in our work, but in the published reports
of it.
Dr, John S. Fulton, Baltimore: I find myself greatly inter-
ested in this discussion, and particularly in the remarks of
Dr. Baker and Dr. Holt, concerning the questionable uses
which are so often made of statistics. Statistics have always
been greatly abused, but their adaptability to misuse is only
the reverse of the very high utility for the best purposes.
Numbers have no morals. At an early period in the contro-
versy between St. Louis and Chicago concerning the Chicago
drainage canal, the St. Louis Health Department sent a circu-
lar letter to all the physicians, calling their attention to the
frequency of error in the diagnosis of typhoid fever, and par-
ticularly to the careless use of vague terms, such as "contin-
ued" fever, "malarial" fever, "typho malarial" fever, and
other expressions of uncertainty in diagnosis. This corre-
spondence promptly resulted in an apparent increase of ty-
phoid fever in St. Louis, and it was not noticed until long
afterward that the increase was fully explained by a cor-
responding decline in a few other particulars of morbidity
and mortality.
A little later, in Maryland, we planned a simple experi-
ment to test the reliability of our certificates of death from
pneumonia. Our circular letter, to all the physicians in the
State, asked them to distinguish more clearly between lobar
pneumonia, and broncho pneumonia, and when death was
due to the pneumonias which occur in consequence of measles,
whooping cough, grip, etc., to be careful about specifying the
primary causes. The apparent great diminution of pneumonia
mortality, which followed this correspondence, was wholly ac-
counted for by this circular letter, but an over-enthusiastic
student of statistics might have made a stirring story of the
great conquest we seemed to be making, when, in fact, we were
simply making a better arrangement of the same numbers.
About that time, the City of Chicago was enjoying the
promotion of pneumonia to the captaincy of the "Men of
Death." The Health Department was actively disputing the
DISCUSSION 309
right of tuberculosis to hold the title "Captain of the Men of
Death." The propaganda of the Health Department was
highly suggestive and pneumonia appeared to be making a
powerful race for the championship. It is entirely probable
that the apparent increase in pneumonia was fully balanced
by diminutions in mortality from measles, whooping cough,
grip, etc., the whole numbers undergoing no change what-
ever.
One must remember that it is unusual for a death certificate
to mention only one cause of death. The certificate asks
for the secondary as well as for the primary cause of death.
But one person is dead, however, and only one cause of
death can figure in the statistics. We must sacrifice part of
our information for the sake of recording the more important
part. This distinction is generally made in accordance with
a well established international understanding, but it is im-
possible to wholly exclude personal judgment, and that means
an element of bias.
The registration of births is now making substantial pro-
gress in the United States, and eventually, no doubt, we shall
outlive the national reproach of indifference to this duty. Dr.
Baker spoke in a spirited way about the needs of immediate
registration of births. In the older countries, where there is
a generous time allowed for the registration of births, they
are now discussing the need of immediate "notification" of
births, as if they might require two separate acts of informa-
tion about births. In Maryland, births must be registered
within four days. A recent prosecution by the State Depart-
ment of Health was of unusual interest. This prosecution
was based on information to the effect that a living birth,
had occurred, that death had followed on the same day, and
that the body had been disposed of on the premises, without
a burial permit, a registration of death or a registration of
birth. When the case came to trial, it was found that the
body was that of a foetus of four months. The physician was
convicted of failure to report a birth. We have no legal
definition of a stillbirth in this country, nor does European
practice furnish us a good definition.
We must have more information about ante-natal mortal-
ity, and much could be learned from the records of still-
births. For a thousand children born alive, about 605 have
perished either in or out of the uterus before their proper
birthday. That statement may lead to some confusion, un-
less you can give up the idea that a birthday is a biologic
fixture. Age is reckoned from one's birthday, but our true
310 VITAL AND SOCIAL STATISTICS
ages may be a good many days younger or older than we
believe. At all events, about 1,605 pregnancies are required
to bring 1,000 babies alive on their proper birthdays. More
than 600 will have died before that time. Fully one-third
of that mortality of infancy, which we say is preventable,
is not preventable by measures applied after the birthday.
For the purposes of restricting this kind of infantile mor-
tality, we must take into account the whole period of utero
gestation ; we must understand that one-third of the mortality
of the first year following birth, results from causes arising
in the nine months preceding birth.
Dr. C. E. Ford, Cleveland: In reference to Dr. Holt's state-
ment concerning the publication of reports of births, I wish
to say that in Cleveland, several years ago, we found that
undue advantage was taken of this information by druggists,
patent medicine men, and credit furniture houses. Poor fam-
ilies were loaded up with things they did not need, and their
finances were seriously embarrassed. Dr. Baker spoke of a
personal investigation as to feeding, in a given number of
families. Some years ago we made a similar investigation in
Cleveland, one inquiry being made of the mother, and the
other of the physician. Ninety-eight babies out of a hundred
that had died had not been breast-fed. Another investiga-
tion was made this year, and it was interesting to note, by
way of comparison, that seventy-four per cent of those that
died had not been breast-fed.
Dr. Philip Van Ingen, New York: Dr. Woodward has brought
out the importance of stillbirth records. In speaking of
infant mortality rates, we do not include stillbirths, and often
forget the great loss due to accidents or conditions occurring
during or before birth. In New York City, from 43 to 45 in
every 1,000 pregnancies end in the loss of the product of con-
ception before birth.
For the first time in the history of this country, we have
from the Census Bureau figures from widely scattered areas
on mortality by age groups under one year, In studying these
one thing has been impressed upon me very strongly, and that
is the need of more uniform methods of tabulating our sta-
tistics.
Suppose we are interested in the deaths under one month
of age. When we look at the figures for Memphis we find
that of the 345 deaths under one year of age, 27.5 per cent oc-
curred during the first month, while for the whole registration
DISCUSSION 311
area, 37.6 per cent of the mortality in the first year of life is
credited to the first month. This looks like a very good
record for Memphis. But if we look a little farther, we will
see that not a single death is credited to the first day of life.
In the registration area nearly ten per cent of the first year
mortality occurs in the first day. I presume that all such
deaths were classed as stillbirths, and not counted as deaths.
Mr. Lewis Meriam, Federal Children's Bureau, Washington, D. C. :
The Federal Children's Bureau has been trying to make birth
registration popular, trying especially to interest the women
of the country in it. The first pamphlet issued by the new
Bureau was entitled "Birth Eegistration, an aid in protecting
the lives and rights of children; necessity for extending the
registration area." After the publication of this pamphlet
Dr. Wilbur suggested a method for interesting the women in
birth registration through the women's clubs, on the theory
that when the women of the country demand that the births
of their children be registered the task of the registration of-
ficials will be greatly simplified. Our method is to write to
the state presidents of the various women's organizations ask-
ing them to suggest persons in the different towns who would
be glad to help us in making a test of the completeness of
registration in their communities. We ask the women desig-
nated by the state officers to name committees in the different
towns and have each member secure in any way, except
through the newspapers, addresses of several children born
during the preceding year and then go to the registration
official and find if those children have been registered. We
have done this in many States and are meeting with cheer-
ful responses from the women. When an organized body of
women learns through an actual test performed by some of
their number that the babies of the community are not receiv-
ing the recognition from the State that the law requires and
when they begin to publish this fact broadcast something
ought to happen for the improvement of birth registration.
Dr. S. Josephine Baker, of New York: As part of our class-
ification of the mortality statistics in New York City certain
deaths are given as they occur in dwellings and institutions.
These figures are presented at their face value and are not in-
tended as a criticism of the institutions. Institutions that are
really babies' hospitals and that take sick babies should not
be classified with the institutions that are maintained for
foundling babies who are, in a large majority of instances,
well. The combined classification of this nature is mislead-
310 VITAL AND SOCIAL STATISTICS
ages may be a good many days younger or older than we
believe. At all events, about 1,605 pregnancies are required
to bring 1,000 babies alive on their proper birthdays. More
than 600 will have died before that time. Fully one-third
of that mortality of infancy, which we say is preventable,
is not preventable by measures applied after the birthday.
For the purposes of restricting this kind of infantile mor-
tality, we must take into account the whole period of utero
gestation ; we must understand that one-third of the mortality
of the first year following birth, results from causes arising
in the nine months preceding birth.
Dr. C. E. Ford, Cleveland: In reference to Dr. Holt's state-
ment concerning the publication of reports of births, I wish
to say that in Cleveland, several years ago, we found that
undue advantage was taken of this information by druggists,
patent medicine men, and credit furniture houses. Poor fam-
ilies were loaded up with things they did not need, and their
finances were seriously embarrassed. Dr. Baker spoke of a
personal investigation as to feeding, in a given number of
families. Some years ago we made a similar investigation in
Cleveland, one inquiry being made of the mother, and the
other of the physician. Ninety-eight babies out of a hundred
that had died had not been breast-fed. Another investiga-
tion was made this year, and it was interesting to note, by
way of comparison, that seventy-four per cent of those that
died had not been breast-fed.
Dr. Philip Van Ingen, New York: Dr. Woodward has brought
out the importance of stillbirth records. In speaking of
infant mortality rates, we do not include stillbirths, and often
forget the great loss due to accidents or conditions occurring
during or before birth. In New York City, from 43 to 45 in
every 1,000 pregnancies end in the loss of the product of con-
ception before birth.
For the first time in the history of this country, we have
from the Census Bureau figures from widely scattered areas
on mortality by age groups under one year. In studying these
one thing has been impressed upon me very strongly, and that
is the need of more uniform methods of tabulating our sta-
tistics.
Suppose we are interested in the deaths under one month
of age. When we look at the figures for Memphis we find
that of the 345 deaths under one year of age, 27.5 per cent oc-
curred during the first month, while for the whole registration
DISCUSSION 311
area, 37.6 per cent of the mortality in the first year of life is
credited to the first month. This looks like a very good
record for Memphis. But if we look a little farther, we will
see that not a single death is credited to the first day of life.
In the registration area nearly ten per cent of the first year
mortality occurs in the first day. I presume that all such
deaths were classed as stillbirths, and not counted as deaths.
Mr. lewis Meriam, Federal Children's Bureau, Washington, D. C. :
The Federal Children's Bureau has been trying to make birth
registration popular, trying especially to interest the women
of the country in it. The first pamphlet issued by the new
Bureau was entitled "Birth Registration, an aid in protecting
the lives and rights of children; necessity for extending the
registration area." After the publication of this pamphlet
Dr. Wilbur suggested a method for interesting the women in
birth registration through the women's clubs, on the theory
that when the women of the country demand that the births
of their children be registered the task of the registration of-
ficials will be greatly simplified. Our method is to write to
the state presidents of the various women's organizations ask-
ing them to suggest persons in the different towns who would
be glad to help us in making a test of the completeness of
registration in their communities. We ask the women desig-
nated by the state officers to name committees in the different
towns and have each member secure in any way, except
through the newspapers, addresses of several children born
during the preceding year and then go to the registration
official and find if those children have been registered. We
have done this in many States and are meeting with cheer-
ful responses from the women. When an organized body of
women learns through an actual test performed by some of
their number that the babies of the community are not receiv-
ing the recognition from the State that the law requires and
when they begin to publish this fact broadcast something
ought to happen for the improvement of birth registration.
Dr. S. Josephine Baker, of New York: As part of our class-
ification of the mortality statistics in New York City certain
deaths are given as they occur in dwellings and institutions.
These figures are presented at their face value and are not in-
tended as a criticism of the institutions. Institutions that are
really babies' hospitals and that take sick babies should not
be classified with the institutions that are maintained for
foundling babies who are, in a large majority of instances,
well. The combined classification of this nature is mislead-
312 VITAL AND SOCIAL STATISTICS
ing. Whenever a baby ceases to attend a milk station the case
is followed up until it is clearly evident that the child is abso-
lutely well or, if ill, the case is followed until the termina-
tion of the illness is known. Whenever a baby that has been
in attendance at a milk station dies, whether under the care
of a private physician, a children's clinic or a hospital, the
death is recorded against the milk station. In order to doubly
guard this fact and to have our milk station statistics as ac-
curate as possible, during the past summer from June 15th
to September 15th I have had every death of a baby under one
year of age in New York City investigated to find out whether
or not it had ever been in attendance at a milk station or
had ever received a visit from a visiting nurse. In this way
we have been able to inform the various milk stations of the
deaths which should be counted in their records. Some of
the milk stations are most conscientious regarding this mat-
ter, but there are others that go under the name of milk sta-
tions and yet -have no educational work, that is, they have
no doctors or nurses to follow up the patients in their homes,
consequently when babies cease to attend such stations it is
not possible for the stations to know whether or not they are
ill or if death has occurred. We have been very anxious to
determine the absolute value of the milk stations and I feel
very strongly that in order to do this we must be absolutely
honest with ourselves and take discredit as well as credit for
everything that occurs in relation to milk station work. Our
object is to find out its real value and not to make a record,
Mrs. William Lowell Putnam, Boston, Mass: The registration
of stillbirths seems to me to be a very important matter, and
one which is very much overlooked. If the stillbirths were
correctly reported and registered, I cannot but feel it would
have more to do than anything else in bringing before the
public the importance of prenatal care. We have been doing
prenatal work in Boston for four and a half years. I be-
lieve we were the pioneers in this movement. We have found
that we can improve the work constantly as it goes along.
For the last two years our stillbirths have not exceeded 18.6
per thousand. In the City of Boston at large they have been
39.3 for the last year and 39.9 the year before. In the Bor-
ough of Manhattan last year they were 48.6 per thousand.
We have also been enabled largely to reduce the percentage
of premature births. Last year we had only four-tenths of
one per cent of premature births, and we feel that must re-
dound toward the general health of the community.
PROGRESS JN VITAL STATISTICS AND BIRTH REGISTRATION
CRESSY L. WILBUR, Ml D., Bureau of the Census, Washington, D. C.
During the present year laws based on the model bill pro-
viding for the registration of births and deaths have been
adopted in Arkansas, North Carolina, and Tennessee, and for
births alone in Delaware. Earnest efforts have been made
to procure such legislation in Georgia, Illinois, Iowa, and
other States. The campaign once begun never ceases until
the victory is won, so that it is merely a question of time be-
fore these States will have adequate legislation.
The laws recently passed in Mississippi and Virginia have
begun to yield practical results. The Mississippi law, with
the beginning of this month, has been in operation for its first
year. A detailed statement of the results is not available,
but 30,000 births have been registered, of which practically
all would not have been recorded if the law had not been
passed. There are many difficulties in the way of successful
registration in the far South, but the law is a success and its
continued support is all that is necessary for thoroughly
satisfactory results.
In Virginia the model bill has been in operation a little
longer, namely, from June 14, 1912, to the present time. For
the first year of its operation nearly 50,000 births were
recorded. This does not represent all the births that occurred,
but the proportion is fairly high and it only requires more
cordial support on the part of the medical profession and
necessary pressure to enforce penalties for neglect by physi-
cians and midwives to obtain complete returns. The registra-
tion of deaths has been somewhat better, so much so that the
Director of the Census has authorized the admission of Vir-
ginia as a registration State for the calendar year 1913.
A very important feature of the statistical progress of the
year has been the adoption in New York of revised legislation
based largely on the model law. The registration of births
in New York City has been greatly improved within the past
few years by more thorough enforcement of the law, but the
registration in the State at large has not been so good. It is
hoped that the new law, if thoroughly organized and carried
out with prompt enforcement of the penalties when required,
313
314 PROGRESS IN VITAL STATISTICS
will make the registration of births in the Empire State com-
plete and serve as a model for the enforcement of such legisla-
tion in other States.
A most notable publication for students of infant mortal-
ity is the recently issued Seventy-fourth Annual Eeport of the
Registrar-General on Births, Deaths, and Marriages in Eng-
iand and Wales for the year 1911. Doctor Stevenson, the
medical superintendent of statistics and editor of this report,
bias given special attention to some most important and inter-
esting phases of infant mortality, among them the study of
)ccupations of fathers as related to the incidence of mortality
;>y ages and causes under the first year of life. You may
perhaps remember that at the Baltimore meeting I urged that
the -high rate of infantile mortality was not a necessary con-
lition of human life. The results shown by Doctor Steven-
son for certain selected occupations, in which special care or
attention may presumably be given to the infants, would indi-
cate that for a large group the infantile mortality may be
exceedingly low. A prominent constituent of this group are
medical practitioners whose children showed an infantile
mortality of only 39 per 1,000 as compared with the general
rate of all occupations for the year of about 130, and of 171
In the occupations, chief among them general laborers, show-
ing the highest infant mortality. The whole report will re-
pay most careful study, and is an indication of some of the
useful data that we should have for this country if only we
2ould obtain the thorough registration of births, which lies
it the foundation of the figures given.
Through the courtesy of Dr. Antonio Vidal, who is present,
[ have had the pleasure of examining the proofs of the text
and tables of the report on demography of the Anuario Demo-
grfico de 1911, Departmento Nacional de Higiene-Oficina
Demogrdfica. This report is a notable one, because, for the
first time, it contains vital statistics for the entire Argentine
Republic. By vital statistics in Argentina is not meant mor-
tality alone, but births, stillbirths, deaths, and marriages as
well. Argentina is a vast country. If superimposed upon the
United States it would extend beyond our northern border
in the region of Hudson's Bay down to the southern tip
)f Florida. It is not densely populated, and many of the
lifficulties that we have encountered in the registration
)f vital statistics have to be met also in Argentina. It is
gratifying indeed, therefore, that success has been attained
>y our southern neighbor, and I hope that the time may come,
lot too far in the future, when we may also say that there is
DISCUSSION 315
complete registration of the vital statistics, births, marriages,
deaths and divorces also, which are more important in the
United States than in Argentina in every State of the
Union.
DISCUSSION
Dr. Antonio Vidal, Department of Health, Buenos Aires, Argen-
tina: The topic which is studied in this section: "Vital and
Social Statistics" interests me very much, and also interests
my country, which has just decided to take a new census. We
cannot overestimate the importance of this matter as re-
gards the investigations and work of public hygiene. Nor can
we forget today that these investigations, if they must have
a real scientific character, must be based on positive data.
To obtain these figures, to add them and to compare them,
connecting them with various useful factors, and to ac-
complish all this through the best, the most uniform and
internationalized procedure, is to accomplish a work of
fundamental importance. This progress is the certain basis
for future advancement. Good and careful statistics are need-
ed in hygiene and are an indispensable tool in its various
forms of technique. I have noted the grasp that this idea
has on the minds of the hygienists of this country with satis-
faction, and I have followed it in many of the studies pub-
lished in the Transactions of the American Association for
Study and Prevention of Infant Mortality and also of the
American Association of Public Health. I am also particu-
larly impressed by the advanced and scientific manner in
which Dr. Cressy L. Wilbur, chief of this Division, in the
Census Bureau, has compiled and commented on them; his
work is highly appreciated in Argentina, as in other countries.
Let us hope that the complete and strict birth and death reg-
istration in all the Union will be obtained and that all the
difficulties it struggles w r ith be overcome.
Fortunately, Argentina has just overcome the difficulties
which are met with in compiling the vital statistics of a na-
tion. First the nation, and then the various provinces, have
been enacting laws regarding the "Civil Register," with ob-
ligatory enrollment of births, deaths and civil acts, under
severe penalties for failure to register. In this manner a
mere computation of results gives us total figures for our
entire country. The first demographic statistics of the Ar-
gentine Republic are those for the year 1911. The National
Bureau of Hygiene has done this work under the direction
316 VITAL AND SOCIAL STATISTICS
of Dr. Jose Penna. (The Demographic Section is a part of
this Bureau and its chief is Dr. Adela Zauchinger.)
We promise to keep technical and other students informed
of what interests them in our work, since the Argentines
greatly wish to interchange scientific and cultural relations
between both countries. The principal figures and propor-
tions which have been obtained for the whole country for the
year 1911 as regards births, stillbirths, general and child
mortality are as follows: The proportions are calculated on
the Republic's having a population of 6,612,816, which is cer-
tainly less than the forthcoming general census will give us.
Births, 262,317. Proportion per thousand, 39.3. (In comparison
with 19 countries, Argentina occupies third place, after Rus-
sia and Roumania.) Stillbirths, 9,049. Proportion, 3.44 still-
births for every 100 children born alive. (Argentina occupies
an average position in this respect, more favorable than Japan,
Belgium, France, Holland, Switzerland and Sweden.) Gen-
eral mortality, 125,727. Proportion, 18.09 per 1,000. (Propor-
tion nearly equal to that of Germany ; exceeds that of France,
Italy, Spain, Russia, Roumania; less than that of Belgium,
England, Holland, Switzerland and Sweden.) Deaths in early
childhood between and 2 years, represent 78.6 per cent of
the infant mortality and 38.34 per cent of the general mortal-
ity. It should be particularly noted that in some parts of the
country deaths of very young children reach such a high
proportion that they comprise half of the total mortality.
I will not linger longer over comparative appreciations or
on technical details. I will merely state that I have estimated
a maximum figure of 14,000 children whose lives can be saved
in Argentina by the application of hygiene and preventive
medicine. These lives to be saved can be called the "Crop
of Puericulture" a crop to be gleaned but not already harv-
ested. This computation should approximate what has been
done in other countries.
The Chairman : That is a very encouraging report from our
sister republic. We are glad to have Dr. Vidal with us.
Miss Van Trump, Washington: The health officer probably
does not realize with what interest sociologists and social
workers watch for these reports. In March, 1910, a statement
was published that in District No. 12 of the City of Wash-
ington more deaths had occurred in a certain area than for the
city as a whole. The social workers of that district got to-
gether, and we are trying now to lower that death rate and
DISCUSSION 317
trying to get together the different constructive forces. And
now we would like the health department to send its investi-
gator and make another investigation and another report, to
find out whether we have practically applied that informa-
tion.
The Chairman: I will now call upon Dr. Woodward to close
the discussion.
Dr. Woodward: In connection with what Miss Van Trump
says it may be interesting to know of the methods by which
we try to apply our vital statistics to practical purposes. This
District of Columbia is only a small area but it is utterly use-
less for me as health officer to know that the death rate in an
area of even sixty square miles is 17.73; I cannot effectually
cover even that area with my force. So years ago we divided
the entire District into what we designated "vital statistics
districts/ 7 and since then we have compiled our statistics for
each such district separately. For each district we know the
population and the deaths from different diseases. So we
group them together in these restricted areas, compare one
area with the other, and thus determine which is prima facie
the most insanitary. Suppose Vital Statistics District No. 5
has a high death rate and No. 8 a low death rate, but that we
find in No. 5 a large colored population. We know that the
colored people have a high death rate, and therefore the high
death rate in No. 5 may be due simply to the race composi-
tion of the population. In another district which has a high
death rate we may find a hospital or another institution that
accounts for the apparently excessive mortality, notwithstand-
ing the fact that all deaths in hospitals and other institutions
are, as far as practicable, charged back to the last residence
of the deceased and not to the hospital.
Dr. Fulton said we have no purpose in studying vital sta-
tistics. If we have not, we might just as well not collect
them. The trouble is we have had no purpose in doing so, but
we must have a very definite purpose, and that is to secure
information that will lead us to intelligent action. The
minute we begin to look ahead and see that we must take some
action based upon the information we get, we will no longer
try to fool ourselves or anyone else. A man may try to fool
himself into believing a thing, but he will not long persist in
trying to fool himself into doing a certain thing. The study
of statistics with a view to action will lead us to an honest
study of them.
318 VITAL AND SOCIAL STATISTICS
In all institutional death certificates in this District we
have two statements, one of which enables us the better to
interpret the other. The certificate requires a statement of
the duration of the last illness and of the length of time the
deceased was an inmate of the institution. When anyone dies
in an institution, the institutional authorities make out the
death certificate. If an infant has been sick eighteen days and
dies, the hospital doctor is the one who records that and not
the milk station physician. I do not like conclusions drawn
from statistics by statisticians. A bookkeeper may tell you
how your balance stands, but he cannot tell you why it is that
way; that is the work of the business man. We have a good
illustration of this in the discussion between Dr. Holt and Dr.
Baker. Dr. Holt thinks that milk stations do certain things
and institutions do certain others. Dr. Baker says some milk
stations do and some do not. She further says that while
some institutions deal largely with sick babies, other deal
largely with well babies, and that you may have groups of
institutional infants more or less fairly comparable to milk
station infants. We have to study statistics with a great deal
of insight, and we have to apply them with a great deal of
imagination.
Eeference has been made to the use of the published names
of parents and children born, .for advertising purposes. That
has never come to my notice. We do not publish the ad-
dresses. Of course, a search might be made in the directory
for such addresses, but if we found that being done, we would
stop publication.
Question: Do you publish the names of illegitimate chil-
dren?
Dr. Woodward: We do not. The physician or midwife
need report nothing that discloses the identity of the parents
or of the child. They simply write where the names of the
parents would go the word "illegitimate." They can leave
off the rest. This assists us in getting a fair return of illegiti-
macy. In one section of our population for the past two
years we found between 20 and 25 per cent of the births have
been frankly and openly reported as illegitimate. In an-
other group only about two or three per cent. If we did not
permit the names to be omitted I doubt if we would get those
returns. We have had men come who were willing to pay for
the names and addresses of the newly-born children, but de-
clined to let them copy the names. One carried the matter
DISCUSSION 319
to the corporation counsel and I was told that I had no choice.
I had to let them do it. But the law was changed and now we
do not let those names be copied.
Dr. Baker referred to erroneous diagnoses as an element of
error. That will always be an element of error until we have
every body examined post mortem. Possibly some errors will
creep in them. But the error is no greater if as great, in
the living cases than it is in the dead cases; because when a
doctor is required to state his diagnosis as to the causes of
death and gives a death certificate, he knows the account is
closed. On the other hand, if he has to record the nature
of the illness from which a living patient is suffering, that is
with a view to an investigation, he will be quite as careful,
or even more careful, to make sure that his diagnosis is as
nearly accurate as he can make it. With respect to all such
matters we have to trust to what is sometimes called the law
of the long run. The larger the number of data upon which
our conclusions are based, the less we will be liable to error.
Say ten deaths from pneumonia of 100 cases, the factor of
error of diagnosis would be reduced by the increased number
of cases under consideration. This very fact that we cannot
rely on the statements of the mothers of dead, babies, nor on
the statements of the mothers of mil babies, is probably the
correct reason for getting the information we can for the
mothers of sicfc babies, in the hope that they would tell the
unbiased facts to save their little ones.
GENERAL SESSION
Monday, November 17th, 2.30 P. M.
PART I.
REPORTS ON BABY-SAVING ACTIVITIES IN THE DISTRICT OF
COLUMBIA
DR. SAMUEL S. ADAMS, Chairman of tlie Committee on. Local
Arrangements, Presiding?
THE DEPARTMENT OF HEALTH
EFFICIENT BIRTH REGISTRATION
Dr, Arthur L. Murray, Department of Health, District of
Columbia: The ways and means of securing more complete
registration of births is a matter which of recent years has
occupied the attention of every progressive municipality.
Washington aspiring to that class, the Health Department
has devoted serious efforts to improve its birth registration.
For a better insight into the lines along which these efforts
have been directed a brief review of the past is permissible.
By an Act of Congress approved May 3, 1802, the City of
Washington was incorporated but it was not until 1819 7 that
the need of a Health Officer was deemed necessary. By an act
of the Board of Aldermen and Common Council approved
August 4, 1819, a Health Officer for the City of Washington
was first provided. Among the several duties devolving upon
the health officer was the registration of deaths but no mention
was made of births or marriages. However, on April 14, 1821,
the Board of Aldermen and Common Council enacted the
following:
AN ACT TO PEOVIDE FOB THE BEGISTEY OF BIETHS, DEATHS AND MABBIAGES IN
THE CITY OF WASHINGTON
Be it enacted by the Board of Aldermen and Common Council of the
City of Washington, That whenever hereafter any child shall have
been born in the said city, it shall be the duty of the head of the family
in which such child shall have been born, or such person as may for the
time being, have principal charge or superintendence of the affairs of
such, family, to cause to be made out and delivered within six days
after such birth to the commissioner of the ward in which such birth
may have happened a certificate thereof, stating distinctly the date of
320
ARTHUR L. MURRAY, M. D. 321
such birth, the sex and color of such child, and whether stillborn or
not ; which certificate it shall be the duty of said commissioner to deliver
to the health officer of the city for the time being, within six days after
the receipt of the same. (Other paragraphs of this Act related to deaths
and marriages.)
In 1822 by an act of the Board of Aldermen and Common
Council the safeguarding of the health of the City of "Wash-
ington was taken from a health officer and vested in a Board
of Health.
The above law relating to the reporting of births remained
in force until 1853 when the provision requiring the reporting
of births to the ward commissioner was changed to one re-
quiring the reports to be made to the member of the Board
of Health for the ward in which the birth occurred.
As to the manner in which births were reported during this
period I will read two extracts from annual reports of the
president of the Board of Health :
EXTRACT ANNUAL REPORT, THOS. MILLER, PRESIDENT
BOARD OF HEALTH, 1852
"So few returns of marriages and births have been made to the Board*
that no practical benefit would be gained by reporting them. The act
regulating this subject, containing no provision for the enforcement of
its requirements, has been, almost entirely, disregarded by those who
should make returns. It is left to the wisdom of the Councils to say
whether the subject is one of sufficient importance to occupy their at-
tention; and if so, to devise the most effectual method of securing cor-
rect and regular returns." . . .
EXTRACT ANNUAL REPORT, THOS. MILLER, PRESIDENT
BOARD OF HEALTH, 1854
. . . "In concluding this report the Board regrets to state, that
the ordinance relative to the registration of marriages and births is
virtually null and void, not a single return of either have been made
to the Board within the past year."
Apparently the reporting of births with any degree of ac-
curacy was not accomplished until after the enactment of the
following :
AN ACT IN RELATION TO REPORTS OF BIRTHS WITHIN THE DISTRICT OF
COLUMBIA, APPROVED AUGUST 18, 1871
Be it enacted by the Legislative Assembly of the District of Colum-
bia, That it shall be the duty of every physician, accoucher, or midwife,
who shall attend at the birth of any infant within the District of Col-
umbia, to forward a report to the Board of Health of said District
within six days after such birth, stating distinctly the date of birth,
the sex and color of the child thus born, its physical condition, whether
stillborn or not, and the name and nativity of the parents of such child ;
322 THE DEPARTMENT OF HEALTH
and any such physician, accoucher, or midwife, who shall fail to report
as herein required shall be punished by a fine of not less than five or
more than ten dollars for each and every offense.
Under this act it is noted for the first time that the respon-
sibility for reporting births is placed upon the person in at-
tendance. This change apparently stimulated an increased in-
terest in the reporting of births, which reports increased dur-
ing the following three years from 1652 to 3915. This act also
was the first ordinance to carry with it a penalty clause for
failure to report births.
In 1874 the Board of Health which had previously been
granted the power of making regulations decided to consoli-
date and augment the several laws governing vital statistics.
As a result the following was promulgated :
Regulations to secure a full and correct record of vital statistics, in-
cluding the registration of marriages, births, and deaths, the interment,
disinterment, and removal of the dead in the District of Columbia.
The third paragraph of these regulations pertaining to births
read thus :
Third. That any physician, accoucher, midwife, or other person in
charge who shall attend, assist, or advise at the birth of any child
within the District of Columbia, shall report to the registrar aforesaid,
within six days thereafter, stating distinctly the date of birth, sex,
, and color of the child or children born, its or their physical condition,
whether stillborn or not, the full name, nativity, and residence of the
parents, and maiden name of the mother of such child or children.
By an Act of Congress Approved June 11, 1878, an Act to
provide a permanent form of government for the District of
Columbia, the administration of the Health Department was
transferred from a Board of Health to a Health Officer.
For the next thirty-four years the above regulations of the
Board of Health relating to the reporting of births remained
in force. On April 20, 1908, our present law was enacted by
Congress. This law I will take up by sections :
AN ACT TO PBOVIDE FOE THE BETTEB REGISTRATION OF BIETHS IN THE
DISTRICT OF COLUMBIA, AND FOB OTHEB PUBPOSES
[34 Stats., 1010.]
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled, That any physician
or midwife who attends at the birth of any child within the District
of Columbia, and any person whosoever who, in the absence of a physi-
cian or midwife, performs any of the offices usually rendered by such
shall execute or cause to be executed and shall file with the health
officer of said District not later than the Saturday first ensuing after
the expiration of three secular days immediately following the date of
ARTHUR L. MURRAY, M. D. 323
such birth a proper report thereof, written in ink, on a blank furnished
by said health officer, embodying all such data as may be necessary for
the purposes of the Bureau of the Census of the Department of Com-
merce and Labor, and such other data, if any, as the Commissioners of
said District deem needful. So far as relates to any data aforesaid
not based upon the personal observation of the physician, midwife, or
other person by whom report is made every such report shall show the
name and address of the informant and the relationship of said in-
formant to the child born: Provided, however, That if the child born
be illegitimate it shall in no case be necessary for any physician, mid-
wife, or other person to indicate on any report required by this act
any fact or facts whereby the identity of the father or of the mother
or of the child born will be disclosed: And provided further, That no
report need be made of stillbirths when the fetus delivered has appar-
ently not passed the fifth month of utero-gestation.
Upon receipt of any report aforesaid, said health officer shall for-
ward to the father of the child, or, if his address be unknown, to the
mother, an acknowledgment of the receipt of such report, and if the
infant delivered be not stillborn, and such report does not contain the
given name of the child born, a blank form on which the father or
mother may certify over his or her signature the name of such child,
which form, if thus executed and returned to said health officer within
three months next following the date of birth, shall be a part of the
official record of such birth.
Section 1, 1 will separate under three headings :
A. This portion covers the mandatory provision requiring
the reporting of births. Such a requirement had been upon
the statute books in one form or another since 1821.
B. Time limit for reporting births permitting a maximum
period of ten days. Attention will later be called to this
feature of the law.
C. Acknowledgments of births. This provision by which
the department is required to send to the parents an acknowl-
edgement of the receipt of a report of birth is without doubt
one of the most important means of securing complete returns
of births. This law has now been in effect virtually six years
during which time the public has through the receipt of these
acknowledgements been educated to a point where at the
present time failure to receive such an acknowledgement from
the department following a birth calls forth an immediate
inquiry.
SEC. 2. That no person shall, in the District of Columbia, willfully
or negligently certify falsely to any fact whatsoever upon any report
of a birth. And after any such report has been received by the health
officer of said District no person shall alter the same otherwise than
by amendments written independently of the body of the report and
properly dated, signed, and witnessed. No person shall in said District
make any false or fictitious report of a birth or any false or fictitious
transcript of any record of a birth or of a marriage.
324 THE DEPARTMENT OF HEALTH
Section 2. Safeguards and insures the integrity of the offi-
cial returns of births.
SEC. 3. That the reports required by this act shall, when duly filed
with the health officer of the District of Columbia, be a part of the
public records of said District, and any person having an interest in
any particular matter contained or reasonably believed to be contained
therein shall be permitted to inspect such certificates and reports,
during all reasonable hours, without charge, so far as can be done
without interfering with the official use of such certificates by em-
ployees of the health department. The health officer aforesaid shall
be the custodian of all reports filed under the provisions of this act,
and annually, and at such other times as the Commissioners of said
District may direct, shall make and publish abstracts and analysis of
the data therein contained.
Section 3. The latter part especially pertaining to publica-
tion of births is another feature of this act which makes for
a more complete return of births. A birth is usually consid-
ered an important event in the affairs of a family and inasmuch
as the list of reported births is published daily, failure of a
notice of a birth to appear in the papers within due time after
its occurrence is invariably noted by some member of the
family or other interested party and soon calls forth an in-
quiry as to its absence.
SEC. 4. That any person violating any of the provisions of this act
or aiding or abetting in any violation thereof shall be punished by a
fine not exceeding two hundred dollars or by imprisonment for a period
not exceeding ninety days, or by such fine and imprisonment, in the
discretion of the court. And if any report required by this act to be
made within a specified time be not made within the time so specified
each week or part of a week thereafter during which such report has
not been made shall constitute a separate and distinct offense : Provided,
however, That no report aforesaid nor any information which has been
obtained by the prosecuting officer on the basis of such report shall be
receivable in evidence against the person filing the same in any prose-
cution of such person for failure to file such report within the time
allowed by law. Prosecutions under this act shall be in the police
court of the District of Columbia on informations signed by the corpo-
ration counsel of said District or by one of his assistants.
Section 4. Penalty, which is very rarely invoked owing to
the proviso, and further, because at the present time flagrant
cases of neglect to report births are very rare.
SBC. 5. That this act shall take effect from and after the expiration
of the six months immediately following its passage, and from and
after that time all acts and parts of acts contrary to the provisions
of this act or inconsistent therewith shall be, and the same are hereby,
repealed. Approved March 1, 1907.
ARTHUR L. MURRAY, M. D. 325
Section 5. This section needs no comment.
It will be seen from the above that the law and the penalty
have not been nearly as effective means of bringing about more
complete returns of births as have been the several features
whereby the public have been educated to demand and to see
that such records are properly returned by those in attendance.
Several requirements of recent date as that of certificates
of births for school purposes and for the granting of permits
to work under the child labor law have in a great many in-
stances aroused parents 7 interest in the matter of seeing that
their children's births are duly reported.
Each year as the public become more and more conversant
with their rights and their responsibilities in regard to the re-
porting of births so also will the returns of births be better
safeguarded and more carefully watched for omissions.
An index of the relative completeness of the returns of births
is a matter which usually is very difficult to obtain, especially
in a city the size of Washington. The Health Officer has, how-
ever, devised a method by which a fair estimate of the com-
pleteness of the returns of births can be made. Each week
the deaths of all infants under one year who were born in the
District of Columbia are checked up as to the reports of their
births. This method has been followed for two years and the
yearly results are as follows :
PERCENTAGE OF BIRTHS REPORTED IN LOCAL BORN INFANTS DYING DUBING THE
FIRST YEAR OF LIFE
1911 94%
1912 96%
Assuming, and I believe the presumption to be logical, that
the ratio of reported births for the District of Columbia is
proportionate to the births found reported in local born in-
fants dying during the first year of life, we believe that at
the present time our registration of births represents at least
96 per cent of all the births occurring in the District of
Columbia.
It will be recalled that in the first section of our present
law attention was invited to the time limit for the reporting
of births, which limit may in some cases extend over a period
of ten days. This time limit we believe to be unnecessarily
long, and have, therefore, recommended that this section be
amended as follows :
AN ACT
To amend an Act entitled "An Act to provide for the better registration
of births in the District of Columbia, and for other purposes,"
approved March first, nineteen hundred and seven.
326 THE INSTRUCTIVE VISITING NURSE SOCIETY
Be It enacted by the Senate and House of Representatives of the
United States of America in 'Congress assembled, That any physician
or midwife who attends at the birth of any child within the District of
Columbia, and any person whomsoever, who, in the absence of a phy-
sician or midwife, performs any of the offices usually rendered by
such, shall execute, or cause to be executed, and shall file with the
health officer of said District within twenty-four hours immediately
following the date of such birth a proper report thereof, written in ink,
on a blank furnished by said health officer, embodying all such data
as may be necessary for the purposes of the Bureau of the Census of the
Department of Commerce and Labor. So that as relates to any data
aforesaid not based upon the personal observation of the physician,
midwife, or other person by whom report is made, every such report
shall show the name and address of the informant and the relationship
of said informant to the child born: Provided, however^ That if the
child born be illegitimate it shall in no case be necessary for any phy-
sician, midwife, or other person to indicate on any report required by
this Act any fact or facts whereby the identity of the father or of the
mother or of the child born will be disclosed: And provided further,
That no report need be made of stillbirths when the fetus delivered
has apparently not passed the fifth month of utero-gestation.
Upon receipt of any report aforesaid, said health officer shall for-
ward to the father of the child, or, if his address be unknown, to the
mother, an acknowledgment of the receipt of such report, and if the
infant delivered be not stillborn, and such report does not contain the
given, name of the child born, a blank form on which the father or
mother may certify over his or her signature the name of such child,
which form, if thus executed and returned to said health officer within
three months next following the date of birth, shall be a part of the
official record of such birth.
Although as yet this amendment has not been enacted it is
most sincerely hoped that within the near future our law re-
lating to the reporting of births will thus be improved.
THE INSTRUCTIVE VISITING NURSE SOCIETY OF THE DISTRICT
OF COLUMBIA
Miss Isabel Strong: Whenever we are asked about work in
Washington we feel a little dubious as to our results, and we
hasten to tell you that we have very broad streets and no
tenement houses in Washington, because we know the eye of
the nation is on us and we feel that our alley situation needs
investigating. This year the nurses feel encouraged because
we have heard about the problems of other cities, and our own
do not seem quite so insurmountable. Six years ago Dr.
Woodward asked us to visit all the babies born under the
care of midwives in Washington. We had been brought up
to know that midwives' cases should be avoided. But we
found that there was nothing in that, and we began visiting
the midwives' cases. We never had any trouble; in fact, the
midwives are glad to have us come in, and the families also
ISABEL STRONG 327
are only too glad to have us come and visit the babies. Some
mothers have written to the nurses and asked even if a doc-
tor was in attendance if we wouldn't also come and visit the
babies. Our duties in caring for the midwives' cases were
especially in reference to the eyes, to report on eye conditions
and record our results on the Kussell Sage Foundation record
cards, which we have found very useful. The discharged cases
are sent in to the Health Department every month. In reference
to the eye cases our work is steadily improving. This has
been accomplished in part by the preventive work which the
Health Department is doing through the midwives. Last year
we had twenty-four cases reported, and among the 7,000 babies
we have handled during the six years we have done the work,
there is only one baby in the City of Washington that has lost
the sight of one eye. The rest of the work which the nurses
do is to encourage maternal nursing, to weigh the babies and
to try to overcome superstitions which are rampant among
the colored mothers. Mothers are more and more ready to
nurse their babies and to use the cabbage and pork diet less
frequently. During the year which has ended we observed
2,482 babies and we had 112 deaths. That's a lower death
rate than we had before. The year before it was six and a half
per cent, and last year it was four and a half per cent. We
feel that our six per cent of lost babies need our care most
especially and we hope to reduce this number in the next
year's work. We have not been able to do prenatal nursing
yet in Washington. We have started in one district. Our
own home is situated there and we also have one milk station
there for a consultation bureau, and a hospital which gives
out-patient service for the lying-in patients. We have divided
the district into two sections and assigned two nurses. Each
nurse is to carry her cases through the prenatal and lying-in
periods and postnatal period. By referring these to the milk
station for registration, and visiting the babies frequently, we
hope to keep better track of them. These milk station reports
have been encouraging. We call it the milk station, but
it is more and more a consultation depot. We had 281
babies; 205 were breast-fed and 76 bottle-fed. The babies
are brought in for examination and consultation frequently.
Two doctors give their services and have been most faithful
in attendance; in fact, the work could not have been done
if they had not been so faithful. The nurses have made
900 visits, and about 1,000 visits have been made by the babies
to the station. We haven't found it necessary to hold out any
inducements to the mothers to come, except the permission to
328 THE WOMAN'S CLINIC AUXILIARY
bring their other children also. The work is cooperative. One
of the churches gives us its large, comfortable, lighted and
heated room for consultation, and another church is subsidiz-
ing the milk. With the aid of the Associated Charities and
churches we hope to induce the people to pay out money for
milk for their babies instead of for beer. Out of the 281 babies
we had only nine deaths, which gives a good rate for our milk
station. We have become converted to home modifications
for bottle babies.
THE WOMAN'S CLINIC AUXILIARY
Mrs. John Hays Hammond: It gives me great pleasure to
tell you of the work of The Woman's Clinic Auxiliary. As
this is a new organization, less than two months old, I shall
have to tell you more of what we are planning and are pre-
pared to do, than of work actually accomplished. The Wom-
an's Clinic Auxiliary is an association of women for the con-
duct of a clinic for actual and potential mothers along twen-
tieth century ideals. It is a clinic where patients instead of
medical students are the ones instructed. It is a clinic where
the health, comfort, and convenience of the patient are of
first consideration. Everything is done to make the patients
feel that the clinic is a good place to visit. The waiting room,
instead of having bare walls with uninviting benches, is a
reception room fitted up as a model living room. There are
large easy chairs, shelves filled with good books, current num-
bers of magazines on the library table, banks of ferns and
flowers, a desk with stationery for the use of the "Keep Wells,"
as our patients are called. For health and the prevention of
injury and disease, rather than disease and its cure are the
objects of study. Expectant mothers are encouraged to come
and get advice how to keep well, how to be mothers of babies
possessed with a splendid birth equipment of biological capital.
The Woman's Clinic Auxiliary is a clinic that aims to meet
the needs of special classes. First the hours are from 5 to
7 P. M., so that working girls may visit the clinic without
loss of time from work. Second, the clinic is attended by
women physicians, though we have some of the best men in
Washington on our consulting staff. Many women prefer to
be treated by women. Third, it aims to meet the need of a
large class of self-respecting citizens who would not think of
applying to the Associated Charities, to the Board of Chari-
ties, or to the Physician of the Poor for assistance, yet whose
income is such that they are unable to pay the fees of a
physician. We charge a fee suited to the income of the pati-
MRS. JOHN HAYS HAMMOND 329
ent and the necessary expenditures. If a patient is unable to
pay anything she is treated and furnished medicine free.
Fourth, we are undertaking special lines of work which will
contribute to the reduction of infant mortality and to the wel-
fare of child and mother.
To accomplish these ends we have organized an out-patient
maternity department, are fitting up a room for child hygiene,
and shall organize and conduct a school of hygiene and prac-
tical nursing.
The out-patient maternity department is under the direc-
tion of our superintendent, Dr. Elnora C. Folkmar, who is as-
sisted by a competent staff of ten women physicians and two
men consultants. Six of these physicians are responsible in
turn for a period of two months for the care of all cases.
The department as at present organized provides for :
1. Course of instruction for expectant mothers at the clinic.
2. Examinations at regular periods of expectant mothers at the
clinic.
3. Prenatal care of expectant mothers both at the clinic and
at their homes. At least one prenatal visit is made by a
staff physician at the home of the patient.
4. Delivery of patient at her home by a competent physician.
5. Post partum care. The physician makes as many visits as
are necesary to care for mother and child and to dis-
charge the patient obstetrically cured. Through coopera-
tion with the Instructive Visiting Nurse Association, a
nurse makes a daily visit for ten days to care for mother
and child.
6. Weekly consultations for mothers and babies.
The out-patient maternity service is at present limited to
white women. We are, however, able to refer calls from col-
ored cases to the Woman's Clinic, at 1237 T Street, which can
send physicians to care for such cases.
Expenses. This service is rendered without cost to the very
poor. But, wherever possible, at least two dollars is collected
to pay expense of materials used. Patients able to pay some-
thing for the service pay either $5.00 or $10.00, depending on
income and expenses. One-half of this amount is paid at
time of second visit to the clinic or of visit of physician to
home of patient, the balance at time of delivery. When over
|5.00 is received, one-half this sum is turned over to the doctor
in charge of the case, the other half goes into the out-patient
maternity fund.
Hospital facilities. As yet we have no hospital facilities
for the care of abnormal cases. These have to be referred to
other institutions, where unfortunately, there are no women
330 PROVIDENCE HOSPITAL
on the visiting staff. As patients apply to us because they
wish to be attended by women physicians, we hope soon to
make an agreement with a hospital having good maternity facil-
ities whereby our physicians can attend our cases.
We are planning the organization of a school of hygiene
and practical nursing. There is need in Washington for a
class of trained attendants of the sick who can be secured
for a salary of $10 to $12 a week. We shall give a course
of one year; six months to be work and study at the clinic,
and six months to be spent as student nurses in the homes
of the poor able to pay from |2.00 to $5.00 a week. The
student work would be under the supervision of a graduate
nurse. This will be a boon to many a poor woman, espe-
cially to maternity cases.
And lastly, we are organizing a child hygiene service. This
provides not only for consultations for mothers of young in-
fants, but for the regular observation of the physical and
mental development of children as determined by approved
tests.
PROVIDEWCB HOSPITAL
and
THE MILK COMMITTEE OF THE MEDICAL SOCIETY OF THE
DISTRICT OF COLUMBIA
*Dr. G-. Lloyd Magruder: I would like to add the records of
work done by some other institutions along this same line.
In South Washington work was started five years ago and has
continued without a break. Today there are between 150 and
200 children under observation being properly taken care of
by the mothers under instruction. The effort to secure breast-
feeding is paramount. Providence Hospital has conducted
this work two years and is very active in the work now. I
have a letter from the Sister Superior, as follows :
DE. G. L. MAGBTJDEB:
Dear Doctor Replying to your communication concerning milk sta-
tion and infant welfare work at Providence Hospital during 1912 and
1913, we wish to say that we have had unusual success in our Out-Door
Obstetrical Department, Children's Dispensary, and the newly-built Day
Nursery and Milk Laboratory. While we have been dispensing milk
since 1908, averaging 600 feedings monthly during that period, the
better facilities of our new Nursery and Milk Laboratory Building,
erected last May at a cost of $10,000, promise well for the extension
of this work. All feeding cases are controlled through the Pediatric,
Dispensary and Out-Door Obstetrical Departments, and milk is dis-
pensed only on prescription. Pasteurized whole milk is used in modi-
fication, with repasteurization of the finished mixture before sealing.
* Died January, 1914.
G. LLOYD MAGRUDER, M. D. 331
Some infants were kept on the grounds of the Day Nursery in the
open air--during the day especially the difficult feeding cases. Many
atrophic infants were also treated in the pediatric wards of the hospital.
I could within 24 hours give you detailed statistics. With best wishes,
I am, Sincerely,
SISTEE MABY BEECHMANS, Pres.
The United States Government is deeply interested in this
problem of improved feeding. I read from the report of the
Surgeon-General of the Bureau of Public Health, "Joint let-
ter dated April 4th, 1912, was received from the committee
representing the Washington Section of the Women's Welfare
Department of the National Civic Federation and the Associa-
tion for the Prevention of Tuberculosis in the District of Col-
umbia, urging that the study be made by the service in co-
operation with the Bureau of Animal Industry and Agricul-
ture as to the effects of pasteurization on the nutritive value
of milk, and also the relative value of raw and pasteurized
milk as a food for infants and invalids." I would also report
a splendid work being done at the Washington Home for
Foundlings. When this institution put its babies on pasteur-
ized milk there was an immediate improvement. Out of 110
babies there were only five deaths, they having been fed on
pasteurized milk continuously during the past year. The
loss during the past year was four out of a total of 77 chil-
dren. This is the lowest infant mortality that the institution
has ever had. By comparison for the last ten years we found
that the average has been 21 per year, the highest in 1904,
with 43 deaths and the lowest in 1906 with 7 deaths. The
average for the five years ending with 1910 was 9.2 deaths per
year. During last year there was some diarrhea and the milk
was brought to the boiling point. Not one of the five deaths
was from diarrheal trouble. Another important movement
in Washington is the work of the Committee of the Medical
Society of the District of Columbia, which appointed a com-
mittee for the study of the milk problem of Washington. The
report will be ready this winter. A recommendation was made
that no milk should be sold without the recommendation of
the Health Department. Congress passed a law authorizing
that work, and Washington has the honor of being the first
city in the world to require such action, and it has been
copied the world over.
ASSOCIATED CHARITIES OF WASHINGTON
Miss Bell: The Associated Charities of the District of Col-
umbia is deeply interested in everything that pertains to in-
332 THE ASSOCIATED CHARITIES
fant welfare. Its work for the rehabilitation of families in
need brings its district visitors constantly in touch with ques-
tions relating to the "saving of the babies."
It stands ready to prevent the expectant mother from over-
working by either supplementing the income or adjusting the
domestic relations so that others may do her work.
It is willing to supply milk or other nourishing food to the
expectant mother if necessary.
It reports all cases of expectant motherhood to special
nurses for babies.
It discourages the employment of midwives and is anxious
to help in the campaign for the proper lessening and super-
vision of all midwives.
It stands ready to adjust conditions so that no woman shall
need either to part with, or wean her baby on account of pov-
erty. This is sometimes done in cooperation with the Juvenile
Court delinquent husband sometimes by organizing relief
among relatives and friends and other organizations and some-
times by use of moral suasion on the woman herself.
It maintains during the summer months a hospital camp for
children under two years of age suffering from intestinal dis-
eases. Not only can the child be cared for in the open air
under the care of skilled physicians and nurses, but the
mother may go with the baby and learn from actual experience
the best method of caring for it. The Associated Charities
believes this educational work means much to the community
as the trained mother will not only care for this one child
and possibly three or four more, but she will also be an influ-
ence in her neighborhood.
Over and above this summer work, the Associated Charities
is interested in the welfare of unmarried mothers with chil-
dren, and while it has no special branch or department for this
work, its visitors come in touch with a number of such in-
stances every year, and this is the only organization dealing
with women and illegitimate children outside of institutions
and the work in this line is growing heavier every year. Not
that there is more immorality or more traffic in babies, but
that the mothers are finding out that there are friends able and
willing to help them keep their babies and get them back to a
normal position in life. This group of applicants as may be
well understood requires a special tact and patience in the
kind of treatment afforded them. To persuade the mother to
keep the child in the face of critical publicity is no easy
task. Yet the saving of the mother morally and the saving
of the baby physically often turn upon the success of the
MISS BELL 333
plan. Experience has shown that these girls can be dealt
with better as individuals in private homes being fitted for
normal life than congregated in homes with a big H. (1) The
Associated Charities boards the woman and child when she
leaves the hospital too weak to work. (2) Investigates thor-
oughly whether it is best for her to return to her family and
also what she is best fitted for in the line of work. (3) Tries
to locate the man who is responsible and bring him to justice.
(4 It gets positions for the women where they can have their
babies with them. Many times it gets a special training for
these girls to increase their efficiency. (5) It furnishes them
with a friend.
We need in Washington more stringent regulations regard-
ing the practice in midwifery and the conduct of private
boarding homes for babies. We have no law at the present time
requiring the licensing of such homes by the Board of Health
and the Board of Charities. We believe that all childrens' in-
stitutions, particularly those caring for infants, should be sub-
ject to the most careful and regular sanitary inspection. The
Associated Charities is desirous to see legislation to accom-
plish the end in view. There is, for example, in this city at
the present time an institution condemned by the Charities
Endorsement Committee, representing the Board of Trade, the
Chamber of Commerce, and the Board of Charities. This
institution opens its doors to children and mothers with
infants, and is in no sense answerable to any supervisory
body. Furthermore, we believe that the present method of
registering the births of illegitimate children by which the
physician or midwife is excused from reporting the identity
of the mother or putative father is against sound public pol-
icy and should be corrected. We should like very much to
see this Association take up this question of registering in
some of its sessions and advise the proper mode of procedure
from the point of view of the welfare of the infant.
Thanks to the activity of the Diet Kitchen, the Straus Lab-
oratory, and subsequently the establishment of the milk sta-
tions conducted by Mr. George M. Oyster as a private benev-
olence, modified and pasteurized milk has been available for
the mothers in our poorer quarters for several years past. This
work, as explained to you, is now being taken over by different
agencies, notably the Washington Diet Kitchen through its
Georgetown station, and the Settlements. The Associated
Charities is distinctly in sympathy with any movement which
carries the education of the mother back into the home through
334 THE BABY HOSPITAL CAMP
the visiting nurse, and tends to encourage natural rather than
artificial feeding. The emphasis placed by this Association
upon prenatal work is one with which we are distinctly in
sympathy.
THE BABY HOSPITAL CAMP
Dr. Louise Taylor-Jones: Of the different lines of infant wel-
fare work in Washington, this, the Baby Hospital Camp, is
the latest to be developed. We have lived through the second
summer and feel that we are incorporated in the baby-saving
work of our city. The camp is maintained by the Summer
Outings Committee of the Associated Charities and cooperates
with all societies doing infant welfare work.
It is situated six miles directly north of here in Eock
Creek Park. It is elevated, surrounded by trees and al-
together an ideal spot. The house is old, but with the addi-
tion of several porches, it is all that could be desired for the
work at present. One effective feature is the screening, for
not only is every part of the building and porches screened,
but each part is screened from the other parts, thus preventing
the fly that may be so unfortunate as to enter the front hallway
from reaching the babies' porch.
After twenty-four hours or more of isolation, the babies live
on the porches day and night. The nursery is used only for
bathing the babies and for their belongings, provision being
made for individual face towels, bath towels, clothes, soap and
thermometers. All are carefully labelled and have their own
special places. The Diet Kitchen is in charge of a graduate
nurse, who modifies the milk according to the physician's
prescription.
In addition to the actual work of trying to save the babies'
lives and making them well, an effort is made to do that which
may prove more far-reaching in its good, namely, the training
of the mothers. The hope is to give them a knowledge which
will enable them to keep their babies well after they get home
and keep well also other babies that * may come later. In
developing the plan it seemed best to introduce the mothers to
one thing at a time; first, to have the baby on the babies'
porch, the mothers doing only certain things for the baby at
certain times under supervision. Gradually she is given more
duties in connection with the baby and his care until finally,
as he recovers, his crib is placed on the porch with her bed
and she has full responsibility under the nurse's supervision.
MES. ARCHIBALD HOPKINS 335
By this method we can get the mothers much more readily
into good habits with the baby. The mothers always improve
much in health too, a tribute to the fresh air and excellent
food, and the aim is to have them develop in character, as well,
At present the accommodations allow for 13 babies and 8
mothers.
WOMEN'S WELFARE DEPARTMENT OF THE NATIONAL CIVIC
FEDERATION
Mrs. Archibald Hopkins : My subject makes the connection
between infant mortality and the housing problem, which is
the paramount question now before the Welfare Department
of the National Civic Federation. Our Housing Committee
found conditions in the alleys absolutely unfit for habitation.
In these alleys down in Foggy Bottom the death rate of the
children used to be fifty per cent higher than the death rate
on the adjacent street, with only a little brick shanty between
them. The death rate was one out of every three. Now it is
one out of every four born in the alley. Some one said it was
just as well because those children would grow up to be crim-
inals anyway if they lived. But that is not the point of view
accepted by the Women's Department of the Civic Federa-
tion. We found that nothing could be done but to wipe out
the alleys, and after two years of hard work we have almost
arrived. That is, we have all the statistics and we have now
a bill drawn which satisfies the Commissioners and the
Health Officer and the Building Inspector and has gone to
the President and received his approval, with some slight
changes. Then it goes to the two committees of the Senate
and House on the District of Columbia, and it will then go to
Congress. We are greatly indebted to Mrs. Wilson, wife of
our President, for her personally conducted tours. Being
asked to go by the wife of the President, in the White House
motor added a soothing influence. Many realized that they
had no idea of the conditions, although they had lived here
many years; and while they had seen pictures and heard re-
formers who tried to arouse their attention from time to time,
the thing had always quieted down again and the alleys went
on as they were.
The question is asked, "Since when has our beautiful
city become such a terrible sink hole of iniquity and hor-
ror?" I say it has always been so. We are very proud
of what has been done by the Washington Sanitary Housing
Company, which owns 220 house in the southwest of the city,
which are exclusively built for colored people. These houses
336 NATIONAL CIVIC FEDERATION
have porches and good plumbing, and they rent from $7.50 to
|12.50 a month. This enables the company to pay the inves-
tors five per cent and leaves them a sinking fund which
enables them to have two per cent against loss and two per
cent sinking fund. We handle that property, not like the
ordinary agent who goes into a house and yells "Rent" and
when the woman hasn't got the rent asks her to leave. No, a
very persuasive charity worker goes and asks why the rent
is not paid. If it is sickness she does what is necessary. If
it is contagion the patient is removed to a hospital. If the
husband is out of work, work is provided, and if he is drunk
we sober him up. Our work everywhere is wonderfully helped
by the District Nurse Association. We work entirely with
them. Very few people know how much work has been done
since the formation of their society. They don't blow their
own horn, so they need some one else to do it for them. Since
1908 they have worked in all weathers and done an immense
amount of work. For five months they have had a baby nurse.
We should always speak of them as the instructing visiting
nurse association, for the excellent work which they do, and
did before any one knew of it, and in face of obstacles of rais-
ing money and the prejudice that there is about every new
undertaking. One does not mind working, but to have to
beg and beg for a little money to pay for good work gets on
your nerves. People think they are doing so much for you
when they give a trifle, and you are after all doing their work.
These nurses are not ours. The welfare work is not ours, and
surely this alley work is not ours. I feel that those of you who
hold up our hands and strengthen us in this work will do more
to break down the death rate and to help the baby question than
in any other way. We have come to feel that the housing
question is after all the main thing in all the work among the
poor. Provide decent housing where people can live decently,
and the death rate will be reduced. Furthermore, it is no use
to talk about people leading good lives who have to live under
such impossible conditions that the rudiments of decency can-
not be carried out because there is no place to do it. Now we
ask you to have a kindly word for our work in the alleys on
the housing question, and as chairman of the Federation I
invite you to come tomorrow to see what we have done and what
we are trying to do to improve the conditions so that one out
of four babies shall not die, but live because of improved hous-
ing conditions.
REPORT 337
THE INFANT WELFARE STATION OF THE WASHINGTON DIET
KITCHEN ASSOCIATION
Miss Mary Gwynn: The Washington Diet Kitchen Associa-
tion, a philanthropic organization which has for years car-
ried on a charity of providing proper and sufficient nourish-
ment in cases of illness where the circumstances of the pati-
ent were such as to make it impossible to secure the same, in
the spring of the present year decided to hroaden its field
of endeavor. After considerable thought and discussion had
been given to the matter it was agreed that an infant welfare
station offered a very promising project. Therefore, in May
the Infant Welfare Station of the Washington Diet Kitchen
Association, located at 1322 28th St., northwest, was opened.
When the location had been definitely decided upon, with a
view to accomplishing the greatest amount of good in the field
covered, all social and charitable organizations and physicians
whose activities centered in the territory were requested to
cooperate with the station.
The first infant was registered on the 27th day of May, 1913.
Since that date the work of the station has gradually increased
until at the present time 97 infants have been received at the
station.
The station, which has in attendance both a physician and
a nurse, is open from 9 to 12 each morning. This affords op-
portunity for a clinic for the children brought to the station
and also permits of instruction of the mothers in the modifica-
tion of milk.
Four physicians are at present on the staff and their days
of attendance are so arranged that at least one will be present
each day.
The graduate nurse is at the station to receive cases and to
give individual instruction during the morning hours whereas
in the afternoon her time is devoted to visiting the homes
of children registered at the station and cases referred to the
station by other organizations. Milk and eggs are both dis-
tributed at the station and in many cases where the infants
are not brought to the station the milk is delivered to the
home. The advantage of permitting the nurse the afternoon
to visit the homes is manifest. !Not only is she afforded the
opportunity of being constantly in touch with the infants
and the surroundings under which they spend most of their
time and thus placed in a position to offer suggestions and
correct conditions in the home bearing directly upon their
338 WASHINGTON DIET KITCHEN ASSOCIATION
hygiene and welfare, but she is brought in personal contact
with the home and necessarily carries into its life the spirit
of social uplift.
As to the present work of the station some idea may be
gained from the following notes taken from the report for the
past month.
Number of visits to the station 207
Number of visits to homes of babies registered at the
station : 85
Number of visits to referred cases 22
Amount of milk distributed daily 20 to 28 quarts
This station is the first agency in the District to teach home
modification, using individual families as units for instruc-
tion. Many predicted failure in the matter of instruction in
home modification, believing our large colored population made
local conditions peculiarly unfavorable. This, however, was
found to be mistaken as the negroes are natural cooks and it
was only necessary to teach them the reason for absolute clean-
liness in preparing the infant milk to have apt pupils. There
were some few discouraging cases, but in numbers they were
a decided minority.
The work of the station is extending in ways unthought of
at the time of its conception, new avenues of usefulness being
developed almost daily. A young ladies' auxiliary has been
formed, one member of which visits and teaches a seven-year-
old boy who has been paralyzed for three years and unable to
attend school. Other members of the auxiliary are doing social
service visiting to the homes.
The latest venture of the station is to be a better babies 7
contest, the first ever held in Washington. This contest is not
to be the useless type of beauty contest, but instead is to be
based upon a scientific examination as to physical and mental
development. As a means of arousing the interest of parents
and the community in general in the physical and mental con-
ditions of infants, this better babies' contest has been under-
taken. At the time of examination opportunity is also afforded
to bring to the attention of parents any defects noted, how-
ever slight, so that immediate steps may be taken for the cor-
rection of the same.
The Baby Welfare Station is open daily from ten to twelve
in the morning and all who are interested in this work are
cordially invited to visit the station.
REPORTS 339
THE MONDAY EVENIWtt CLUB
The Chairman: We will next hear from the Monday Even-
ing Club, whose representative is Mr. Charles F. Nesbit, its
new president.
Mr. Charles F. Nesbit : Some one asked what the Monday
Evening Club was. If I were not one of its officials, and if
Dr. Van Schaick had not been connected with it, I would say
it's the Who's Who in the Kingdom of God in the City of
Washington. It is the social service committee of charity
workers who get together to study these problems. Its prin-
cipal function is to enlighten the people of Washington through
our meetings and through the press on the present great prob-
lems that affect the civic life of Washington and other cities.
All such work as you are taking up has our heartiest approval.
There is a large amount of publicity given it through our club.
Dr. Edward T. Devine, of New York, predicted six or seven
years ago that America was on the eve of the greatest religious
awakening it had ever known. He called it a religious revival.
Some one asked him why he made such a statement, since it
was believed that the church was losing ground everywhere.
He said he "based it on the fact that the churches are begin-
ning to take an interest in the death rate." He said that that,
to his mind was infallible proof that we were on the eve
of a tremendous religious awakening. We are all taking an
interest in the death rate and beginning to understand what it
means, and what such losses in infant life mean to the future
of our country. I can only give you a word of greeting and
give you godspeed on part of the Monday Evening Club.
CENTRAL MILK COMMITTED-NEIGHBORHOOD HOUSE
Dr. W. J. French : I wish to call the attention of this Asso-
ciation to an organization that has recently come into exist-
ence in Southeast and Southwest Washington. We call it the
Central Milk Committee. When Mr. Oyster ceased giving milk
we found it necessary to do something for the milk stations.
We formed a committee and connected with it are the visiting
nurses and the milk stations. Each station pays a stated sum
each month, and this with the collections for the milk pays
the milk bill. If there is a deficit the committee will appeal to
the general public for aid. Three stations have been in exist-
ence for some time and are doing excellent work. The one at
Neighborhood House has been in existence since April, 1908,
340 REPORTS
without a break. We have handled about 2,000 babies, 1,500
of these at the Neighborhood House. We are handling the milk
for almost all of the children in Southwest Washington, ex-
cept those that are cared for by Providence Hospital. The
death rate at the station at Neighborhood House has never
been more than 4% per cent, and it has been down to 2 per
cent. The other stations make as favorable a showing. The
milk station at Neighborhood House was the first ever estab-
lished in this city to dispense modified milk to babies.
GENERAL SESSION
Monday Afternoon, November 17, 1914 (Continued)
PART EL
TOPIC:
AN IDEAL PLAJST FOR A COMMUNITY'S BABY-SAVING
ACTIVITIES
REV. DR. JOH3V VAN SCHAICK, Jr., of Washington,
Presiding;
THE DEPARTMENT OF HEALTH
Dr, C, E, Ford, Cleveland : Every intelligent community now
realizes that the protection of the health of the child repre-
sents the first duty of any Department of Health, because it is
conserving the greatest national asset, namely, the child the
future father and mother of the nation.
A Bureau of Child Hygiene in a Municipal Department of
Health must, if it is desired that the department consider
every phase of the protection of child life, be built upon a very
broad basis. The factors which enter into the production and
the prevention of illness in children are so numerous that their
presentation may give the impression that if the establishment
of a Department of Child Hygiene were to include these vari-
ous activities would practically not be feasible today. I per-
sonally, however, feel very strongly that owing to the inti-
mate cooperation of the various medical charities, the hos-
pitals, and the universities, with Boards of Health, that there
is every reason to believe that the opportunity now presents
for developing efficient Departments of Child Hygiene in
Boards of Health upon the broad lines to be stated below.
According to my conception, the Department of Child Hygi-
ene ought, as far as possible, to engage in or control every
activity that is necessary to guard the physical welfare of the
child from birth or, better still, before birth, by giving at-
tention to the mother-to-be, until the age of sixteen.
The sub-divisions into which I should divide the activities
of vsuch a Department are as follows :
341
342 THE DEPARTMENT OF HEALTH
I. Prevention of blindness.
II. Reduction of infant mortality
Visiting Nurses
Babies' Dispensary and Hospital
Maternities and Foundlings
Medical Profession
Social Service
Production of Milk; Distribution
III. Supervision of the so-called infant boarding homes and
nurseries.
IV. Supervision of institutions, including orphan asylums, hos-
pitals and dispensaries.
V. Physical examination and supervision of children under
sixteen years of age, applying for mercantile certificates.
VI. Medical supervision of children at schools and kinder-
gartens.
VII. Prenatal care and maternity.
These sub-divisions of the Department of Child Hygiene
have been chosen for practical reasons of organization. Theo-
retically, the inspection of boarding homes and nurseries would
have as its first object, the reduction of infant mortality, and,
therefore, would theoretically come under the head of that sub-
division. Practically, however, it would soon be recognized
that these activities would represent each in themselves, suffi-
cient work for any one individual responsible for carrying
out the duties that devolve upon an officer holding such posi-
tion. From the description of the duties of each sub-division
you will be able to see what is included under the various
headings.
I. THE PREVENTION OF BLINDNESS
Although the economic loss to the nation by diseases of the
eye causing blindness, is less in amount than that due to the
so-called causes of infant mortality, there is, nevertheless, no
other work that should require more earnest attention of a
Department of Child Hygiene than that which has as its ob-
ject, the prevention of blindness. It is true that sentiment
should never be considered when the welfare of the commun-
ity is being discussed, but I believe that there is no one, who
has any heart, who would not be touched beyond all measure
of expression by the sight of a well-developed boy or girl who
has lost vision unnecessarily. The fact that nearly every one
of these cases can be prevented, is, of course, free from senti-
ment, and it adds weight to the former. So I have placed as
the first duty of the Department of Child Hygiene, the pre-
vention of blindness.
C. E. FORD, M. D. 343
This sub-division would be engaged in the following activi-
ties:
The immediate care of every case of eye disease reported to
the Board of Health by a nurse doing this work, either under
the direction of the family physician, if the parents are in a
position to afford one, or if not, under the direction of a physi-
cian especially detailed to the work. This would include the
examination of the discharge by men qualified to do so, in
order to ascertain whether the disease be contagious. In
case the former be true it would devolve upon the physician
and nurse to consider seriously whether it would not be for
the best interests of the child and family that the infant be
sent to a hospital.
Inasmuch as most of the reported contagious eye diseases in
infants occur in cases in charge of midwives, it would seem
rational to entrust this sub-division of the Department of Child
Hygiene with the supervision and control of midwives. That is,
the nurse and physician would at all times be bent upon ascer-
taining whether or not the midwife is practicing according to
law. In case the midwife is not within the law, it would be
their duty to obtain the necessary evidence to make it possible
to have her prosecuted according to the law, and to see that
this evidence is placed in the proper hands. It is understood
that if any physician is found violating the law that the facts
regarding his case be also referred to the proper authorities,
and not to drop the case until the officials, whose duty it is to
prosecute, actually prosecute.
"Practicing according to the law" would include the ques-
tion of licenses and certificates, of proper reporting of births
for state registration purposes, of reporting at the proper time
the appearance of the eye symptoms, and of the instituting
the proper care and treatment to avoid the charge of mal-
practice.
II. THE BEDUCTION OF INFANT MORTALITY
The enormous death rate among infants represents the
greatest economic loss that any civilized nation sustains. It
is not necessary for me to call your attention to the numerous
activities exerted by foreign countries with the hope of check-
ing this important deficit. You are also aware that the
Departments of Health of various cities of our own country,
especially that of New York, are spending large sums of money
in the organization of work whose object is to reduce infant
mortality. I wish, however, to impress you with this fact,
344 THE DEPARTMENT OP HEALTH
that by scientifically and methodically working for the reduc-
tion of infant mortality, one not only saves the child from
death by bad food and too much heat, but also from diseases
of latter life, especially tuberculosis, by making the human
body at its very appearance upon this earth as resistant to
untoward influences as it is possible. In other words, the
activities carried on to reduce infant mortality represent, at
the same time, the greatest preventive measure that is exerted
today, to check the spread of tuberculosis, with the possible
exception of isolating the so-called "open cases."
This sub-division should include the following activities :
1. The control of the proper registration of births, and in
case the law is not sufficient, the bringing of influences to bear
upon the proper authorities to remedy such law or to enact a
new law. It may be stated at this point that a change of the
length of time of ten days after birth to make a report, to three
days would give the agencies, working to educate the mothers
in the proper nursing of their infants, a better opportunity for
good results.
2. Prophylactic Babies' Dispensaries. By these are not
meant simply the equipment and the records, but physicians
and nurses trained in this special work. The physical examina-
tion of the mother and child, by the physician, must form the
basis for action. The nurse is the physician's right hand, who
not only aids him in the dispensary, but goes as well into the
homes to demonstrate to the mother how to carry out the
physician's directions, to encourage her in doing this, and to
become the friend of the entire family with the sole object in
view of not only caring for the infant in a preventive way, but
for the entire family as well. She must therefore also learn
for her own benefit and also for that of the physician, who is
to intelligently advise her, as to the material circumstances
of the family and the hygienic condition of the home and its
surroundings.
Inasmuch as the nurse continues to visit the home until
the infant has reached the age of fifteen months ( and this time
should be lengthened) and further as babies are constantly
present in the homes that need the help most, a Babies' Dis-
pensary nurse has a greater opportunity of applying preven-
tive medicine to the family as a whole, than any other
agency, medical or sociological.
So a Prophylactic Babies' Dispensary must recognize the
various factors in a child's surroundings that might harm it,
and know the best means to remedy these evils, and further
to make the child more resistant. The question of housing
C. E. FORD, M. D. 345
with its sub-divisions of lighting, ventilation, cleanliness, air
space, etc., and the question of the temperature and humidity
of the atmosphere within the house and without, are important
points to be considered. The keynote to the reduction of in-
fant mortality rests mainly in the proper nourishment of the
child, and especially in the nursing of the child by its own
mother. The first object of the Prophylactic Babies' Dispen-
saries must be to have mothers nurse their children properly,
and for this reason an early birth registration and an intimate
cooperation between the midwives and the physician confining
mothers, is essential.
Inasmuch as it is difficult to educate mothers, especially
those who have household duties, to see that it is for their own
good that they learn how to keep their baby well, it is necessary
that this education be made as accessible and as easy to them
as possible, and this means two things, that the distance
from the house to the center of instruction, that is, the
Prophylactic Dispensary, and also the time spent at this
Prophylactic Dispensary, be as short as is compatible with
good work. It is, therefore, much to be desired that instead of
having one large dispensary for the entire city, it is preferred
to have many so-called branch dispensaries on a small scale
in a limited district. In order to cover the city thoroughly it
would be necessary to have, I should say, about forty such
Prophylactic Babies' Dispensaries, although we have but fif-
teen for 65,000 inhabitants one for every 15,000 to 20,000
inhabitants.
3. The production, preparation and distribution of milk
for children whose parents are unable to pay for certified milk
and which children, according to the decision of a dispensary
physician or a family physician who is directing the prepara-
tion of the food, are in need of artificial food.
Inasmuch as the needs of the Department of Child Hygiene
in the other activities that have been or will be mentioned in
this discussion, are so great and will entail such a large
expenditure of money, it is my belief this work ought to be car-
ried out by private charity at the outset or until the time
comes when appropriations to this department will be suffi-
ciently great to enable it to assume this responsibility.
There is, however, one step in this special sub-division re-
garding milk that ought to be made immediately, and that is,
the encouragement by this department through the Board of
Health of the establishment of a municipal milk farm.
It may be idealistic to require a pathogenic bacteria free
milk for everyone, but it is absolutely necessary for the in-
346 THE DEPARTMENT OF HEALTH
fants and the younger child. How great a part dirty milk
plays in the production of disease and ensuing deaths is not
definitely known, but it is nevertheless an important factor
among the array of infant killers and that its elimination
is a thing well worth striving for. A clean wholesome milk
is roughly a milk that is obtained from healthy cows in a
clean manner by healthy men and so handled as to prevent
an excess of ten thousand bacteria per cc. Incidentally,
this latter statement is rather absurd in that the character of
the bacteria is not specifically stated. A necessary requisite
in keeping the number of bacteria as low as this is the im-
portant and efficient cooling immediately after milking, and
the further maintenance of a low temperature in clean milk
cans or containers until it is to be used for the preparation
of the infants' food in the home or in the laboratory. Another
requirement necessary of any milk to be regarded as "whole-
some" is freedom from the tubercle bacillus, be they human or
bovine. In order to be certain that a given milk is free from
the bovine tubercle bacillus, it is necessary that a farm be
large enough to enable the producer to raise his own herd. It
is further necessary that he have land sufficient to make it pos-
sible to isolate those cattle with tuberculosis, those positively
free from tuberculosis, those of which there is still doubt as
to the presence or absence of tuberculosis, and last, but not
the least important, the calves that are being raised to main-
tain the numerical strength of the herd. The farmer must
be in a position to develop this plan in order to correctly make
use of the tuberculin test, and also to prevent reinfection of
his tuberculosis free herd by such cows which do not react to
the tuberculin test and which may nevertheless be infected
with tuberculosis. Otherwise, his expensive efforts are abso-
lutely futile and would represent to him a large loss of time
and money.
From the above stated facts it becomes very clear that a
small farmer cannot carry out the plan for want of capital.
So it appears that the only solution of the problem would be
that either companies of large capital or the government (muni-
cipal or otherwise) must take over the production of milk.
From the standpoint of a health official I favor municipal
pasteurization.
It is well known that the simple boiling of milk removes
the danger of infection with the tubercle bacilli and we have,
therefore, a very simple measure for the avoidance of this
source of disease. True it is there is still some doubt as to the
dangerous effects upon the organism of the infant by boiling
C. B. FORD, M. D. 347
milk, but it can be unreservedly stated that these cases are
rare. However, it is no more than right that the few infants
who can not stand boiled milk be enabled to secure a raw milk
that embodies no harm to them. So if it would be possible to
develop the plan mentioned for the production of raw milk,
absolutely free of tubercle bacteria, the difficulties could be
met by simply producing a clean milk and having the milk
boiled when the food is prepared for the infant.
The cost of production of clean milk is more than that
of common milk. It costs about twelve cents a quart delivered.
Of course, this varies in various cities depending upon many
factors. Twelve cents per quart is the price that but few of
our citizens can afford to pay.
In order that the infants of parents who cannot afford to
buy this milk at this price may get what is essential for their
normal and healthful development it is necessary that some-
one pay the difference between the price they can pay and the
actual cost of the milk. Up to this time private or philan-
thropic institutions have carried this burden, but the time is
ripe when this tax should be carried by all the people. Hence,
it is the plain duty of the city to produce and deliver a pure
milk for infant feeding.
The City of Cleveland has now a herd of one hundred and
eighty cows, about eighty of which are now producing from one
hundred and ninety to two hundred gallons of milk per day.
This is supplied to institutions, and later, with the develop-
ment of the herd, it is the purpose to make available milk
for the purpose of infant feeding. Of course, this work is not
all new. The City of Berlin has a very large farm colony and
uses this, among other things, to produce the amount of milk
required by it for its own infant hospitals, infant asylums and
dispensaries.
4. Instructions of the girls at school in infant hygiene to
be given as a part of the regular curriculum. The establish-
ment of such a course in the schools would represent the high-
est type of prevention of infant mortality, because it would
instill into the mothers of the next generation a responsibil-
ity that would, if efficiently developed, make the educational
work of the present Prophylactic Babies' Dispensaries un-
necessary. So besides being the proper thing to do, it would
be the most economical in the end. This is a duty of the
Board of Education, but inasmuch as the teachers of today
have not been trained in this subject, it is much to be desired
that they acquire this knowledge, and while they are pre-
348 THE DEPARTMENT OF HEALTH
paring, the Board of Health or some philanthropic organiza-
tion share responsibility with the Board of Education.
5. Improvement of housing conditions. Eeference to this
subject has been made and it is placed under a separate head-
ing to emphasize its importance. As stated above, this activity
of the Department of Child Hygiene should resolve itself into
intimate cooperation with the "Department of Housing" by
referring poor housing conditions to that Department for cor-
rection.
Here again a nurse doing so-called "infant mortality work"
has the opportunity of being an active reporting agent to the
"Department of Housing."
6. The prevention of neglect of children by their parents.
This activity would utilize the power vested in the Board
of Health to force a parent, who for some reason or other
neglects the physical condition of his child, to assume
his responsibility, or in case he does not, to assume it for
him until the child has recovered, or the parent has evi-
denced the desire to do his duty. It may be stated that such
an activity would not be limited to infants, but would apply
to other children as well, and would, therefore, come under
the other divisions of the Department's work.
7. Cooperation with other departments of the municipal
governments, with the state, federal and foreign governments,
and with the local, state, national, and international philan-
thropic organizations, in every manner that would mean an
improvement of the child, directly or indirectly, through a
betterment of its condition of living.
III. SUPERVISION OF THE SO-CALLED INFANT BOARDING HOMES
AND NURSERIES
By the so-called "infant boarding homes" are meant institu-
tions in charge of some private individual, usually a widow or
a "practical" nurse, where more than two infants are kept,
and for whose care either the parents or some association pays
from $2.00 to $3.00 per week. The individuals operating such
homes do this as a means of livelihood, and therefore, desire,
as a rule, to have more than two, and if possible six to ten
babies in their home. It is well known that the infants in
such boarding homes receive, as a rule, inadequate care, not
because the person operating this home desires to wilfully
harm the child, but because she cannot for the amount paid
C. B. FORD, M. D. 349
her, afford to give the child the supervision and attention that
is necessary to keep it well. This service would include the
supervision of the child's feeding by a competent physician,
as well as the care of the child during illness. For this reason
in various parts of this country, and also in foreign countries,
especially in Hungary, where the state assumes this great re-
sponsibility in a most efficient manner, it has been found that
many of these disadvantages disappear when but one child is
placed in a home.
The Department of Child Hygiene should establish and have
at hand a sufficiently large list of homes that have been in-
vestigated as to hygiene and sanitation, and as to the health,
character, and trustworthiness of the family, and have been
found acceptable. This would place the Department of Child
Hygiene in a position to recommend homes to any organiza-
tion or individual, and to include in the contract with the
person in charge of the home, the requirement that as soon
as an infant is accepted, that infant be under medical super-
vision of the Department of Child Hygiene, requiring the fos-
ter-mother to present her foster-child at regular intervals at
the Prophylactic Babies' Dispensary located in her district.
In this manner, good use could be made of the Prophylactic
Babies' Dispensaries, and there never need be doubt as to the
quality of the food given these infants by reason of such
supervision. It would, however, be necessary to place one
nurse in charge of this work, not only to be responsible to-
gether with the respective dispensary nurse, for the health of
the child, but also to take complaints from any source and
investigate these complaints, and further to find and inves-
tigate new homes and add them to the list, in order that a
reserve number may always be available. This plan would
make it possible to have not only boarding homes for one child
on artificial feeding, but also "infant boarding homes" for one
child with wet nursing. For the physical examination of the
wet nurses and the infants to be wet nursed, and also for the
inspection of nurseries, it would be well to add to the Depart-
ment the services of a physician and nurse who would be re-
sponsible for this activity.
I may say at this point that the Department of Child
Hygiene has a list of homes and is in conjunction with the
Humane Society organizing this work.
IV. Under this division should be included the supervision
of nurseries. And under the supervision of the nurseries, I
should like to include the regular daily visit to each nursery,
350 THE DEPARTMENT OF HEALTH
and the inspection of the children there. The Day Nursery
and Free Kindergarten Association does this work under
supervision in Cleveland.
IV. SUPERVISION OF INSTITUTIONS, INCLUDING ORPHAN ASYLUMS,
HOSPITALS AND DISPENSARIES
The duty of this division of the Department of Child
Hygiene would be to see that the rules of the Board of Health
and the state law regarding the hygienic conditions of these
institutions be enforced. The greatest fault with these insti-
tution^ as a rule, is overcrowding, and in the case of asylums,
the very lax manner of admittance, and after admittance, of
isolation. Besides seeing that the letter of the law is obeyed, it
would devolve upon this division of the Department of Child
Hygiene to suggest any improvements to these organizations
that will benefit the children harbored there, and that can
be arranged for at a reasonable expense, and also to call the
attention of the proper authorities to the need of any new law
or any amendment to old laws that might be necessary to
establish proper conditions for the children.
THE RELATION OF BABY-SAVING ACTIVITIES TO THE DEPART-
MENT OP HEALTH AND TO EACH OTHER
Dr. S. Josephine Baker, New York: At our general meeting
the problem of infant mortality was presented to us from two
points of view, one was that it is a community problem, and
the other that it is an individual problem. I think those of
us who have worked in the prevention of infant mortality feel
that, in the last analysis, each mother must save her own
baby. To that extent it is an individual problem, but each
mother has not the power to save her own baby unless she is
given some assistance, that is, there are many features of baby
care that she cannot get for herself, such as the problem of
clean milk, proper housing, pure water, etc., so that in this
respect we must consider it a community problem. In so far
as it is a community problem I believe that the work of preven-
tion of infant mortality should be undertaken by the health
authorities of the community. As we all know, it is an ex-
ceedingly complex problem and so far there has been no health
department or bureau of child hygiene, even under municipal
control, that could look out for all aspects of this many-sided
question, so private philanthropy has undertaken many feat-
ures of this work to show mothers the way in which they may
properly take care of their children and afford them the means
to do so. These private philanthropic agencies have grown up
in most communities quite independent of each other and have
come in time to encroach upon each other's activities, dupli-
cating their efforts and often causing an immense amount of
waste effort I believe that, primarily, the responsibility for
the reduction of infant mortality is a community problem for
the Department of Health, but in many of our towns and even
cities our boards of health are notoriously lax and uninter-
ested in this problem and therefore the private or semi-private
philanthropic and social service agencies are the starting
points from which public opinion must be aroused. I do not
believe that other organizations should do the work which the
Department of Health can do, but there are, as I have stated,
many features of this work which seem to be properly placed
under semi-private control. Where duplication of effort is
found there is need to get together and to organize so that the
351
352 RELATION OF BABY-SAVING ACTIVITIES TO BACH OTHER
greatest good may result to the babies from a well-planned
cooperative effort. This situation of having societies dupli-
cating effort was a common thing in New York City several
years ago, and from the point of view of efficiency it was an
extremely serious situation. The individual societies spent
large amounts of money and so did the Department of Health,
yet their efforts so overlapped that it was not uncommon to
have six or seven nurses making visits to one family. Many
societies were not on friendly terms with others ; there seemed
to be a feeling that if any cooperative effort were made some
of the societies would take undue credit for whatever results
might be obtained, leaving the other societies without proper
credit for their work, so that no one organization was willing
to take the initiative in a cooperative scheme. The Depart-
ment of Health, therefore, thought that it would try to achieve
this result, slowly and systematically. First, we asked rep-
resentatives of the milk stations in the city to come together
and after some preliminary conferences an Association of
Infants' Milk Stations was formed. The city was districted
so that each agency had control of certain districts and there
was no overlapping of territory or duplication of work. A
uniform system of record-keeping was instituted and yet the
individuality of each milk station organization was left un-
disturbed. This cooperative effort was so effective that at the
end of the year I suggested to the milk station association
that we further extend it by asking all of the agencies of the
city who were interested in baby welfare work to join with us
in a larger federation. A general meeting was held, repre-
sentatives from all of the organizations attended, and we now
have what is known as the Babies' Welfare Association, which
is simply a cooperative federation of about eighty agencies
interested in baby welfare work. I have not time to give in
detail the organization of this association at the present time,
but I do want to say that the methods of work are not inter-
fered with. No organization loses its identity or has its
methods of work changed in any particular, but some remark-
able results in a cooperative way have been achieved. For
instance, formerly when a nurse or social worker wished to
enter a baby in a hospital she sometimes had to call up one
hospital after another until the greater part of a day had
been taken up before accommodations could be secured. Now
we have a central office with an executive secretary who is
regularly informed by the sub-committee on hospitals of the
association as to the number of available beds. If any nurse
wishes to place a baby in a hospital she calls up the execu-
M. ADELAIDE NUTTING 353
live secretary, giving the baby's address. Within fifteen
minutes the executive secretary replies, telling her just where
the baby will be received and in less than half an hour the
baby is in a hospital ward. The same sort of cooperation has
been achieved in regard to vacations for babies by the sub-
committee on outings. The sub-committee on social service
work planned a system of relief that is prompt and adequate
and similar statements can be made regarding all of the sub-
committees. Our bookkeeping on infant mortality is more
correct than it has ever been. We have shown just what may
be done by organized effort and I believe that our example
can be followed by any community, large or small. It would
seem that the Department of Health should be the central
agency and take the initiative in this form of organized co-
operative work because it is the one agency that can officially
represent the entire community spirit and life. I believe that
this cooperative movement has had a very marked effect upon
the encouraging reduction of infant mortality which we have
had in New York City during the last four or five years.
THE IDEAL VISITING NURSING
Miss M. Adelaide Nutting, New York: Under an ideal form
of government, I suppose our attitude toward disease would be
about what it now is toward illiteracy. We should be unable to
tolerate it. Health would be looked upon as the right of the
individual which it is the first duty of the state to protect,
to promote and in a measure to compel. Then, I presume,
this high function of the state will not, in any of its various
aspects, be left to the chances of private philanthropy, to
individual enterprise or to the hazards of individual competi-
tion, and any state which desires to endure must look upon the
health of its children as its highest charge, over which it exer-
cises constant and profound solicitude. For this purpose it
will use every agency and instrument at its command, organ-
izing, directing and distributing them to cover its inhabited
territory. It will reach as surely and effectively into remote
country districts as into crowded centers of population, for,
from the point of view of the state, the health of all districts
is equally important.
Among the many agencies at the disposal of the state for
this purpose there will be none, I think, of more definite and
peculiar value, none more widely utilized, none more essential
to a good public health service than its staff of public health
nurses. , [
354 IDEAL VISITING NURSING
An ideal visiting nursing service is, therefore, in my opinion,
a state public health nursing service. Such a body will, of
course, apply itself to that need of the community which is
after careful study found to be most urgent, and the pro-
tection of infant life must inevitably, I think, form a large
share of its work. Just as the great proportion of teachers
in the service of education are occupied in the primary and
elementary schools, guarding and directing the mental growth
of young children, so probably will a very large proportion of
our visiting nurses be occupied in guarding the health of
mothers, infants and young children, working close down to-
ward the beginnings of life when the infant and the child are
measuring their feeble resources against whatever influences,
injurious or destructive, may surround them. A state nursing
service must require of its workers that they be trained and
expert in this branch of work.
Now just as we are recognizing that our work for the pre-
vention of tuberculosis must begin long before there is any
sign of that disease, so in preventing infant mortality we must
begin as far back as it is practicable at present to carry our
efforts, and that will be with the young expectant mother in
the early stages of pregnancy where the conditions under
which she lives and works are hourly helping forward or hind-
ering the healthy growth of the coming child.
The nurse is fortunate in having no barriers to break down
to gain entrance to homes and knowledge of family problems.
As desirable measures for today for utilizing as fully as pos-
sible the resources of visiting nurses in preventive infant mor-
tality, I suppose the following suggestions might prove prac-
ticable.
The employment of visiting nurses in connection with
maternity dispensaries, to watch over expectant mothers and
to give such prenatal instruction as may be needed, and the
employment of the same nurses to visit the mothers after con-
finement to continue the same oversight, instruction and care
just as long as may be necessary. (I cannot think well of a
system which provides such intense specialization as prenatal
and post-partum nurses.) In the same way, just as far as
practicable, I would like to see young mothers, early dis-
charged from maternity wards, followed up in their homes by
visiting nurses to continue oversight over the child as long as
there is any cause for it.
I would provide for inspection and supervision by visiting
nurses of all places where dependent infants are housed,
whether in individual homes, day nurseries or foundling
J. WHITRIDGE WILLIAMS, M. D. 355
asylums, or any other institutions where nurses are not directly
in charge. And even these will need probably a certain super-
vision.
The regular visiting nurse in her daily rounds, the school
nurse in hers, both have exceptional opportunities for giving
instruction to young mothers in their homes, both before and
after their babies are born, and the importance of this aspect
of their work should be constantly urged.
In addition to such informal instruction, the services of
visiting nurses should be constantly utilized in giving more
formal and definite teaching in the care of infants and in the
responsibilities of young mothers to clubs of working girls,
to older school children and to young mothers. There should
be in every visiting nurse's association a kind of educational
division in which one or more nurses give less time to actual
nursing, and more time to such instruction, for to be really
valuable such teaching takes time and thought and special pre-
paration on the part of the one who would teach. Small neigh-
borhood exhibits might form a part of such teaching.
Half a century of experience of visiting nurses in England
seems to point to the importance, if not to the actual necessity
of special maternity training for visiting nurses in rural dis-
tricts and small communities with scattered population. In
a strikingly large number of instances the visiting nurse has
been called upon to actually deliver the mother, because the
doctor did not arrive in time, and in the emergency the nurse
was there and the only available help. There is some evidence
to show that the visiting nurse in this country has often the
same problems to meet, and if this is true, she should be ade-
quately prepared to meet it.
I suppose that continuous education in one form or another
is the great agency which the state will employ for the im-
provement of health, and the ability to teach effectively will be
the most potent weapon which the nurse can carry in her war-
fare against infant mortality. She will, it is true, work for
almost invisible results, and the more successful her work the
less will it be seen.
THE PI, ACE OF THE MATERNITY HOSPITAL IN THE IDEAL PLAN
Dr. J. WMtridge Williams, Baltimore : In an ideal commun-
ity, I do not think that one should speak of a maternity hospi-
tal, for in such a community things should be designated cor-
rectly, and the English term is lying-in or obstetrical hospital.
I must confess to a great prejudice against the former term.
356 THE MATERNITY HOSPITAL
Of course, it comes from Maternity which is good French, but
in this country it is employed as an euphemistic substitute
for the good old English designation, and is reminiscent of
the time when child-bearing and everything connected with it
was considered more or less indecent and referred to with
bated breath.
I shall, however, go a step further and state that I be-
lieve that what is needed in this country is not mere lying-in
hospitals, but institutions based upon much broader lines,
which may be designated as woman's clinics. In the former,
care is provided for the woman in childbirth and for her
newly-born child, but no matter how well it is equipped or
how excellently administered, its prime function must be the
mere physical care of the patients with incidental education
of male and female midwives.
In this country, and to some extent in Great Britain as well,
obstetrics has suffered greatly from the so-called maternity
hospital, with its narrow ideals and its restricted opportuni-
ties. Doubtless, most of the non-medical members of this audi-
ence believe that American women are the recipients of the
most expert obstetrical care in the world, and that obstetrics
has attained its highest development in this country. I am
here to tell you that such is not the case; and while I have
no desire to deny that there are many expert obstetricians, I
have no hesitation in stating that in this country obstetrics is
the most poorly taught of all the major branches of medicine,
and that the average practitioner leaves the medical school
very poorly equipped to carry on this important part of his
work.
This is due to no fault of his own, but is attributable to
the peculiar development of medical education in this coun-
try. Until recently the medical schools were entirely in pri-
vate hands and not under the control of strong universities.
Any one was considered good enough to be made a professor
of obstetrics, and was very fortunate if charitable persons
made it possible for him to direct a small lying-in hospital,
where he might enlarge his own experience and give meagre
instruction to his students. Even now, after the stronger
schools have come under the nominal or actual control of the
universities, somewhat similar conditions prevail, and at the
moment I know of only one school in this country which
possesses adequate facilities for the instruction of its students.
As the professors are usually poorly paid, they are obliged
to devote the greater part of their energy to making a living
by private practice, and necessarily regard the conduct of
the small lying-in hospital and training of students as a very
J. WHITEIDGB WILLIAMS, M. D. 357
secondary consideration. Faulty training, meagre facilities
and lack of time make it impossible for them to investigate
the fundamental problems of the subject, with the result that
our professors are the least productive in the world and have
contributed practically nothing to the scientific side of their
profession. I am sure that you will be surprised when I
tell you that I know of only two Americans who have made
fundamental contributions to the subject and neither of them
were obstetrical teachers.
In my opinion this deplorable condition of affairs will not
be overcome until each of our large medical schools is provided
with a suitably equipped woman's clinic under the control of
a broadly trained professor and an adequate staff, who give
their entire time to the treatment of hospital patients, the
teaching of assistants and students, and the investigation of
problems connected with their work.
You may ask how such a clinic differs from a lying-in hos-
pital? And I would reply in two important particulars: first
by affording opportunity for the connected study of the physio-
logy and pathology of the entire reproductive process in
women, instead of mere child-bearing, and secondly, by train-
ing young physicians to realize that progress can be attained
only by discovering the fundamental laws which underlie the
entire process.
In such an institution, which should contain 100 ward beds,
facilities should be afforded for the instruction of students,
not only in the care of women in labor, but also in everything
which pertains to the relief of the various diseases and abnor-
malities of the generative organs, together with the necessary
provision for social service work, prenatal and post-operative
care. Equally important are adequately equipped laboratories
for anatomical, chemical, pathological and physiological re-
search, with trained and enthusiastic workers and sufficient
funds for apparatus and the necessary technical assistants.
In such a clinic women would not only be delivered and opera-
ted upon in the most approved manner, and students taught the
essentials of practice ; but it would fail of its purpose unless
the greatest stress were laid upon the investigation of the
problems of disease, and unless the students and .assistants
were inculcated with the idea that they are not dealing with
a thoroughly completed subject, but are really assisting in the
first stages of its development.
While we are able to deliver women with reasonable safety, to
repair certain injuries subsequent to child-birth, and to excise
organs which have become too diseased to be useful, it will
surprise you to learn that we are almost absolutely ignorant
358 THE MATERNITY HOSPITAL
concerning the significance of the most fundamental functions
of the female sex, and that we know very little concerning the
nature of most of its diseases and their mode of prevention.
For example, we know as little as did Adam and Eve's first
children as to why labor comes on at a definite time after
conception, or concerning the significance and nature of men-
struation. The latter problem is of especial interest to the
women present, and particularly to those who are interested
in advancing the interests of their sex. Have you ever con-
sidered the economical significance of the fact that three out
of every five women are more or less incapacitated for several
days each month, and that one of them is quite unable to at-
tend to her duties? Granting that the two sexes are possessed
of equal intelligence, it means that women cannot expect to
compete successfully with men ; for until they are able to work
under pressure for thirty days in each month they cannot
expect the same compensation as the men who do so. Gener-
ally speaking, we are only little better able than our grand-
fathers to relieve painful menstruation and there is little
prospect that great progress will be made in that direction
until we learn what normal menstruation means and to what
factors its abnormal manifestations are to be attributed.
One of the great functions of an ideal woman's clinic would
be the study of such problems, which cannot be solved by the
busy practitioner, but which may be solved after years of
patient work by trained scientific investigators who will be
competent to coordinate the results of laboratory research
with the problems presented at the bedside.
Institutions such as I have outlined cannot be expected in
small communities, but it is my hope that they will grad-
ually be established in connection with the strong university
medical schools, as it is only in a true university atmosphere
that they can be expected to fulfill their highest possibilities.
In smaller cities the small lying-in hospital will always serve
a useful purpose in caring for the women of the poorer classes,
but it cannot be expected to fulfill the ideals I have briefly
indicated.
Thoroughly equipped woman's clinics will always be ex-
tremely expensive, as I estimate that one accommodating 100
patients would require an endowment of approximately two
million dollars, exclusive of the original cost of the plant
namely, $60,000 a year for the maintenance of 100 ward pati-
ents and $30,000 a year for the salaries of the medical staff and
for the expenses of teaching and research.
L. BMMBTT HOLT, M. D. 359
Unless adequately endowed, such Institutions will accomp-
lish little more than those now in existence; for what we de-
sire is not only to give the patients the most expert care and
to train competent practitioners, but practically to develop a
new type of medical teacher, who will be free from the dis-
tractions of private practice and thus be able to devote his
entire time to the care of hospital patients, to teaching and to
research. Such men must be adequately paid, and in order
to accomplish their work must be surrounded by a high type
of assistants and have abundant means to carry on expensive
researches.
In communities in which the State has assumed the respon-
sibility for higher education, we may in time expect to see
such institutions supported by the taxpayers, when the wel-
fare of the women and babies will be as carefully looked after
as the health of the cattle and hogs. In the East, however,
such a development will be possible only as the result of
private beneficence, and this will scarcely be forthcoming until
women interest themselves in the matter and impress philan-
thropists with the belief that they can do more for mankind
by fostering scientific investigation of the problems concern-
ing the health of women and young children than by many
of the enterprises to which they now contribute.
I commend agitation of this character to the women who
are particularly interested in the welfare of their sex and feel
sure that it will accomplish far more good than many of the
movements which they are now fostering.
THE PLACE OF THE HOSPITAL IN THE CAMPAIGN FOR THE
REDUCTION OF INFANT MORTALITY
Dr. L. Emmett Holt, New York: Since by far the largest
part of the effort for the reduction of infant mortality is along
lines of the prevention of disease, it is evident that little of
this can be done in the hospital. Preventive work must be
carried on chiefly by those agencies which instruct the public
in infant feeding and hygiene. But those who teach these
subjects, whether as doctors or nurses, must themselves be
taught. As has been said many times during this session, we
must begin by educating the educators.
Twenty-five years ago very little was taught in medical
schools regarding the hygiene of infants or their diseases. To-
day most of the medical schools of the higher grade are giving
some time to this branch of medicine, but more time is needed
360 THE PLACE OF THE HOSPITAL
if much is to be accomplished. For this work the children's
hospital is indispensable. The student must not only have lee
tures on these subjects, he must have the opportunity to see
sick infants, to know to what diseases they are liable, and to
learn how they are to be recognized and treated.
One of the things which detracts most from the value of
vital statistics is the deplorable fact that so many errors of
diagnosis are made by those who sign death certificates. It is
only in hospitals that accurate diagnosis can be learned ; only
in hospitals that the most serious diseases can be observed;
only in hospitals, not in out-patient clinics nor in milk sta-
tions, that very sick infants can be properly cared for. If
our therapeutics of disease in infancy and childhood is to
advance beyond the routine use of a few domestic remedies like
castor oil and paregoric, the diseases of infancy must be
studied seriously and thoroughly by men trained in medical
science.
By all means let everything possible be done to keep the
baby well, but when, in spite of all precautions, he does fall
ill, let us have experienced men and well-equipped institutions
where such cases can be suitably treated, not bungled by the
inexperienced or the ignorant.
Without the special hospital there can be no real special-
ists. Without the hospital and the specialist there can be no
proper teaching of this important branch of medicine. Nurses
also must get their training in well-equipped and organized
special hospitals. The problems connected with very sick chil-
dren cannot be taught nor appreciated by nurses whose only
experience has been in general hospitals for adults or in milk
stations or dispensaries. If life is to be saved, a nurse must
be able to recognize at once when an illness has reached a
really serious stage and requires special advice and treatment.
To hold on to a case until the child is almost in a dying condi-
tion and then transfer it to a hospital is too often the plan
followed. This would not occur if the nurse had received a
training in an infants' hospital and realized how much more
could be done for such cases in a hospital than in the tene-
ment home. We need educated trained nurses, but even more
do we need nurses with special experience who have been
taught to observe sick infants and who know when something
more than their own efforts is demanded.
The infants 7 hospital has perhaps its largest function to per-
form in the investigation of this comparatively new field in
medicine. Many problems in hygiene and feeding are still un-
solved and there are many common diseases of whose causes
J. H. MASON KNOX, M. D. 361
we are still grossly ignorant. It is only by carefully con-
ducted chemical and bacteriological studies, which cannot be
carried on except in well-equipped hospitals, that not only the
causes of disease but the means of prevention can be deter-
mined.
Much in lessening infant mortality could, of course, be done
if we simply devoted our efforts to promulgating truths
already known regarding infant hygiene and infantile dis-
ease, but soon progress would cease. We need not only a pub-
licity campaign and a campaign of education, we must have
continually at work a group of trained men whose researches
shall bring forth new knowledge, who shall teach us what is
vital and what is irrelevant both in prevention and in treat-
ment.
The subject of disease in young children is full of un-
solved problems, which are one by one being cleared up as we
get a better understanding of the basal sciences upon which
medicine rests.
To instruct students, to teach physicians, to train nurses,
we must therefore have the special hospital. To advance
knowledge and put the special branch of diseases of infancy
upon a scientific basis, a special hospital is indispensable.
Only in a hospital can conditions requiring special thera-
peutic measures, whether medical or surgical, be managed, if
life is to be saved. Although there may be treated within
its wards only a small percentage of the infants who fall
sick, let us not think the part filled by the hospital small or
unimportant in the reduction of infant mortality, since the
hospital alone furnishes a place where those who form public
opinion can themselves be taught proper views regarding es-
sential methods of prevention, the most exact means of diag-
nosis and the best means of treatment of the diseases of in-
fancy. The work of the hospital is and always must remain
of fundamental importance, for upon it rests the whole super-
structure of prevention and cure of disease in infants.
THE SOCIAL SERVICE DEPARTMENT IN CHILDREN'S HOSPITALS
Dr. J. H. Mason Knox, Baltimore : The subject of giving the
dependent classes a better chance for health has been well
covered. The social service department is a new feature of
nearly all of our children's hospitals. Those of you who are
familiar with the out-patient work of children's hospitals know
how difficult it is to follow the cases, what a small proportion
362 THE SOCIAL SERVICE DEPARTMENT
of the cases come back for a second visit. The social service
worker receives these people as they come to the clinic, knows
the mother at least by sight, collects the small fee where it is
possible, and forms some opinion of the social status of the
parent. The case goes back to the doctor and is referred to
the social service worker. In the children's clinic at the Johns
Hopkins Hospital eighty per cent of the cases came back the
second time in the last two months, owing to the valuable
services of our social worker. She is in touch with the other
social service forces in the city. She knows, if she cannot
admit a case, what other free beds there are in other hospitals.
She knows where to find a baby nurse for that particular dis-
trict in which the patient lives, and to whom the case can be
referred for feeding; and directions transmitted to the nurse
by telephone are carried out in the home. She makes the
visits and determines whether that case ought or ought not to
pay a small fee. The whole social history of the family is
ascertained. Many cases of treatment can be carried out in
the homes through the co-operation of the social service
worker and the nurse, that would otherwise fill up the wards
unnecessarily. We have now a series of cases of chorea or
St. Vitus' Dance well cared for by district nurses. The im-
portance of the social service work in connection with baby
lives is just beginning to be appreciated. I feel very strongly
that we will do our best for the dependent infants when we
make the welfare stations numerous in our city and have one
nurse at each consultation place. I think a nurse loses that
intimate contact with the mother which she ought to have as
a friend when the districts are made too large. I hope the
time will come when we can have so many districts that we
will put on the list of the nurse not more than 100 to 150
names for her attention. In this way she can be the helper
in all things pertaining to the babies in that small district,
and to the mothers requiring aid. Then maternity cases in
the obstetrical clinic can be referred to her, and she can make
her acquaintance with the mother before the baby comes and
follow up that infant life through its whole period, and she
will be the natural person to carry out any prophylaxis as
far as eyes are concerned. Then, too, she would be the one to
send ill babies to the proper hospital, or, as is done now, to
the Thomas Wilson Sanitarium in summer. It seems to me
until we do develop this intimate and close relationship be-
tween the nurse in a not too large district with the mothers
requiring aid, we will not be doing all that we can to put the
dependent infant on a par with the infant that is born tinder
more fortunate circumstances.
THE FOUNDLING ASYLUM AND THE UNMARRIED MOTHER
Ellen C. Babbitt, New York: The highest mission of the
foundling asylum is to care for the unmarried mother, for
when the mother with her unborn baby is "found," much may
be done for the prevention of the class known as foundlings-
meaning thereby abandoned babies. As a help in finding the
unmarried mother, the prenatal work begun in this country
by the Woman's Municipal League of Boston and now car-
ried on in many cities, is of the greatest value. When the pre-
natal nurse, trained especially for this wrk ? has the unmar-
ried expectant mother under her care, she provides for her
physical, mental and spiritual well-being before the baby's
birth, for her confinement and for after-care.
The foundling asylums which receive the mothers before
their babies are born have opportunities to supervise the pre-
natal hygiene, and to see that the mothers are in good condi-
tion to welcome their babies, and to give them breast milk.
Too often, the confinement expenses in these institutions are
paid by the mothers' scrubbing. If these mothers have more
breast milk than their own babies need, if, by the law of sup-
ply and demand, the supply of breast milk can be increased,
might it not be better to use them as wet nurses, as the Was-
sermann test makes that safe? Or, might not this life-saving
milk be drawn for motherless babies, or for those whose moth-
ers are unable to supply an adequate amount?
What of the prenatal work done by the maternity hospitals
other than those connected directly with the foundling
asylums? Some of them maintain out-patient departments,
keeping the expectant mothers under close supervision, the
best of these departments having nurses going into the homes.
The value of this work is shown in the statistics of the hos-
pitals doing it; especially significant is the large percentage
of supervised mothers who are able to give breast milk to
their babies. The prenatal nurse impresses on the expectant
mother that to nurse her baby is her atonement.
Apart from the medical side of the work of the maternity
hospital, what may be said of the social side of its work? Is
the mother taking care of her baby, and in so doing coming to
love it? Yes, in Queen Charlotte's, in London; no, in many
of our hospitals where the babies are kept in other rooms and
brought to their mothers only at feeding time. This may be
good hospital management, but it is certainly not done with
the best good of the mother in mind. The lessons on the care
of the baby given in the London hospital daily and at the
363
364 THE FOUNDLING ASYLUM
mother's bedside, the baby's bed being beside the mother's,
are with us too often left to the last day, or for the visiting
nurse, in such of the hospitals as have follow-up work.
And what of the hospitals which dismiss the mothers at the
end of ten days or two weeks, what recognition do the unmar-
ried mothers receive of their need at this time? Is the mother
nursing her baby, feeling its dependence upon her? Or has
the baby been weaned in the hospital, perhaps never been
breast-fed? Has the mother's physical need of her baby dur-
ing these first days been overlooked? Much of the harm done
thereby is shown in other hospitals to which the mothers go
later, say the physicians.
Where do these unmarried mothers of ten-day-old, artifici-
ally fed, unloved babies go? Often to the foundling asylums,
where mothers may leave their babies. Where does the blame
lie for the high mortality therein? If the rule laid down by
the Johns Hopkins Hospital, by the Boston Lying-in, and
others, be followed that every mother who is physically able
to do so shall nurse her baby during her stay in the hospital
much good might thereby be done for the mother as well as
for the baby.
If the unmarried mother leaves the hospital, loving and
nursing her baby, her next need is to get into normal rela-
tions as soon as may be, that is, she needs to be in a family.
The most enlightened people who think on these things ar-
range for the reception of the mother with her baby in a care-
fully inspected private family where the money paid for board
will make it worth while to give them good care. Both baby
and mother are kept under medical supervision. As soon as
the mother is able to do regular work, she must be helped to
find it. Here again there is a danger to be avoided. Every
woman does not succeed at housework. A scheme must be
worked out whereby the mother may do the work for which
.she has aptitude, going to it by day and returning to the home
where her baby has been looked after during the day, to care
for it herself at night. This system as followed out in Hun-
gary and by some societies here, has been vastly successful not
only in preventing the deaths of babies, but in saving the
health of many babies and their mothers.
If the mother going to the foundling asylum, asking to have
the asylum take her baby, could be given the money otherwise
paid by the asylum to a foster-mother taking charge of that
baby, might the mother not be encouraged to try to supple-
ment this with her earnings? The statistics given by Hungary
JOHN VAN SCHAICK, D. D. 365
show that the mortality of the illegitimate babies supported
by the Government and kept by their own mothers is lower
than that of such babies boarded with foster-mothers. The
careful supervision given to the babies, who are wards of the
state, includes the mother in its good effects.
THE PART OF THE CHURCH
Rev. Dr. John Van Schaick: If any man doubts the reality of
human progress, I wish he could have attended this session
this afternoon. Or if not, I wish he might take the proceed-
ings of the last annual meeting of this organization and read
them. We have had opened up before us this afternoon differ-
ent avenues of service, different instrumentalities and special-
ties highly organized throughout our community, all making
efforts to save the children. I have to remind you in the clos-
ing hour of this conference that there is another organization
dating back through many centuries, which has organized it-
self among many races and expressed itself in many forms, and
though it has sometimes been said that it was a wrecked and
ruined concern, it has always had a great faith in individuals.
I want to tell you that the greatest help the church can be in
this program is to stick to its distinctive job of making men
feel more that this is God's universe, that we are all His chil-
dren and have our part to do in serving one another. But
we must not stop there. A church ought to know the social
service agencies of its community. It ought to have a survey
in its mind and heart of what is going on around it. It ought
to know what the work of a society like this is. We cannot
preach about it every Sunday, but incidentally, a paragraph
here and a reference there should indicate that a preacher
knows about these things and sympathizes with them and
prays over them and will help to carry on the great work of
education in his parish. And he can get this helpful litera-
ture and help spread it. There are a thousand and one oppor-
tunities to help in this work. Is it the duty of the church to
organize machinery for the carrying on of this work ? I say it
is not. It depends on the community. Time was when all the
hospitals were church hospitals; when all the beggars were
fed at the monastery gate; when all the schools were church
schools. But the history of civilization shows that gradually
the church stripped herself of these functions and the com-
munity took them up and organized them as what are called
secular agencies. But where work needs to be done that is
366 THE PART OP THE CHURCH
not being done, it is tlie business of the church to do it. It
may be a dispensary or a rnilk station. It is the duty of the
church to do it. Here is where we have made our mistake:
Where a community is enlightened and has moved forward
and has organized itself in many different ways, the church
ought not to duplicate efforts or to compete or to stand in
the way of this progress. It should only cooperate with the
existing secular agencies, sometimes by helping to support a
nurse here or there, sometimes only by recognizing an infinitely
better fitted organization like this for doing the work, or rec-
ognizing the work of the associated charities for caring for the
poor, or helping a tuberculosis association face its problem or
the social settlement people to do their work in their neighbor-
hood and institution. The duty of the church is to recognize
that here is an instrumentality through which to send its
workers and to make its application of the great faith that it
has cherished so many centuries. I hope we here in Wash-
ington may do more to cooperate with this great society and
other societies like it.
AMERICAN ASSOCIATION FOB STUDY AND PREVENTION OF
INFANT MORTALITY
AFFILIATED SOCIETIES
REPORTS
1913
The affiliated societies were asked to indicate as far as possible their
activities along the following lines :
I. To what extent does the registration of births serve as the start-
ing point for your work?
II. What proportion of the infant population is reached by the work
of your association?
III. Is your work carried on during the summer months only or
during the entire year?
IV, When was your work started? What effect has it had on infant
morbidity or mortality? Can you give statistics?
V. What connection have you with the Department of Health?
VI. What relation does your work have to other welfare work in
your own city or town?
VII. Do the activities of your association include prenatal as well as
postnatal work?
VIII. If they include prenatal work, please outline the plan followed,
Character of instruction?
By whom given in classes to individuals in their own
homes?
How long has the prenatal work been carried on?
How many mothers have been reached?
Does your association provide obstetrical service?
The effect of this special care and instruction on the health
of the mother and child?
Please give figures, if possible, to show how many of the
babies whose mothers have had this instruction, have been
breastfed for 1 month, 2 months, 3 months, 4 monthsup
to 10 months
IX. Please outline the general plan followed in your postnatal work?
The number of welfare stations?
Character of the instruction given?
Does it include weekly conferences between doctor, mother and
nurse, instruction of mothers in their own homes, nursing
care of sick babies?
Does it include the distribution or sale of milk?
X. How many doctors and nurses are on your staff?
XI. How is your work financed?
367
368 REPORTS
ALABAMA
INFANT WELFARE SOCIETY
Birmingham.
OEGANIZED SEPTEMBER, 1913
PLAN OF WORK
Practically all births reported in poorer districts will be investigated
by the Infant Welfare Nurse
Headquarters of Infant Welfare Nurse to be in the -office of City
Health Department.
Metropolitan Life Insurance gives prenatal instruction to all cases
reported; postnatal care, only where complications exist; provides
obstetrical service, and care to sick babies over one year old.
Graduate nurses give prenatal instruction and postnatal care to all
of their cases. This has been carried on for eighteen months. They
also give obstetrical service.
Associated Charities Nursing Department. Nursing care given all
sick babies. Special care in cases of ophthalmia.
Metropolitan Three nurses on staff. Associated Charities One nurse
one-half time.
CANADA
THE BABIES DISPENSARY GUILD
Hamilton, Ontario
I. From the registration of births, we obtain a mailing list for
"Mother's Letters," which tell the parents of the existence of
the Babies' Dispensary Guild, something of its organization
and purposes, also giving such parents as do not require the
assistance of the Dispensary an opportunity to help the work
financially or to refer to the Dispensary, other parents who
are not as able to meet the expenses entailed in securing
medical attention for their children.
II. During 1912, the birth list numbered in our city 2,554. The
number of cases admitted to the Dispensary in 1912 were
265 (age limit 2 years). Approximately, 10.4 per cent of births.
III. The work is carried on throughout the entire year.
IY. The Dispensary was begun in June, 1911.
The death rate among infants in our city showed some decrease
in the last 3 years, but on account of the rapid increase of
population from immigration, the exact percentage is hard to
calculate (accurately, however. T!he deaths from gastro-
intestinal trouble alone, are steadily on the decline.
1910-43.4% of total deaths.
191127.0% of total deaths.
191225.5% of total deaths.
AFFILIATED SOCIETIES 369
Y. We have no connection with the Department of Health, other
than we refer to them cases of poor housing, faulty sanitation,
etc., when the visiting nurse comes in contact with undesir-
able conditions in homes -visited.
VI. The work of the Babies' Dispensary Guild has no connection
with other welfare work in the city except in a cooperative
way, the Dispensary referring cases to other organizations
under whose work these cases come more directly when occasion
arises, the societies refer cases in the same manner to the
Dispensary.
VII and VIII. During the winter months of 1912, one afternoon a
week was given up to mother's classes, including the cutting
out and making of garments, short talks and demonstrations
given by the nurses on the proper care and clothing of the
infant, and prenatal instruction. The garments made at the
sewing classes were sold for the price of the material, which
was bought at a reduced, -or wholesale rate. Homes of expec-
tant mothers, of cases in attendance at the Dispensary are
visited more frequently and instruction and help given in the
homes as far as possible. The association does not provide
obstetrical service, but cases are referred to the Victorian
Order of Nurses, who devote a great deal of time to this
branch of work. In every case, receiving this instruction,
the mother has been able to breastfeed her infant, if not
entirely, partially, using mixed diet, breast and certified milk
mixture, according to the clinic doctor's orders, approximately
100% for 1 month (85% breastfed entirely) 50% i months
75% for 2 to 3 months; 25% 9 months; none longer period
In no one case where the baby was second or more child, had
the mother nursed the previous baby.
IX. As yet, no branch stations have been formed, daily clinics being
held at the Dispensary to which the mothers bring their babies,
weeldy, or at longer intervals, according to the doctor's orders,
for conference and advice. A doctor and nurse is in. attend-
ance at the clinics daily. Demonstrations of feedings, etc., are
given at the Dispensary, or if occasion demands it, in the
homes, and succeeding visits, averaging about two in a month
are made by the nurse to the homes for further instruction
and advice. Sick babies are called on more frequently, and
assistance given to the mother in the carrying out of any
treatment prescribed. Certified milk in pints and quarts is
brought into the city, and resold to, and delivered to the
homes of, the patients at a greatly reduced rate. Proteid milk
(Meyers and Finklestein's) is the only formula made at the
Dispensary. This milk is not delivered.
X. The Dispensary medical staff consists of twelve doctors, ap-
pointed by the Medical Board, six of whom are in attendance
at the Dispensary for a term of three months, one for each
day of the week. The nursing staff consists a supervising
nurse, a visiting nurse, and during the summer months, a
third nurse, to assist at the daily clinics.
XI. The Babies' Dispensary Guild is supported by voluntary con-
tributions from the general public, membership fees, and a
very small city and provincial grant. A publicity campaign
in 1912, added greatly to this work, the pledges in several
cases extending as far ahead as 1915.
370 REPORTS
The statistical report follows :
Previous number patients admitted 329
Present number patients admitted 371
Total number of patients admitted to Dispensary 700
Number re-admitted 47
Number interviewed, not admitted 84
DISPOSAL OF CASES
To family physician 29
To hospital 19
Discharged, cured 123
Discontinued 197
Deaths (5 gastro intestinal with us over 2 weeks) 23
391
In. regular attendance on clinic roll 158
Total daily clinic attendance 3,310
Total number cases with feedings supervised by medical staff.. 61,464
Average number of cases with feedings, etc., per day 168
MILK DELIVERED
Certified milk 35,991 quarts
Proteid 2,930 quarts
Special 405 quarts
Number new visits for investigation and instruction 502
Number special nursing 161
Number on cases referred 104
Number revisits 2,832
3,599
CASES REFEBEED
To family physician 80
To City Hospital 5
To Out-Door Department Hospital 42
To Relief Officer 4
To Health Department 4
To Tubercular, School nurses, and other public health
organisations 16
154
HELEN N. W. SMITH, Supervising Nurse.
CONNECTICUT
THE INFANT WELFARE ASSOCIATION
New Haven
The Infant Welfare Association of New Haven was started in 1908
as a sub-committee of the Consumer's League, being known as the Pure
Milk Committee. In 1912 it became an independent association under
its present name, but co-operates very closely with the Visiting Nurse
Association, and the New Haven Dispensary. Beyond cordial relations
it has no connection with the Department of Health.
AFFILIATED SOCIETIES 371
The most active season is in summer, four welfare stations being
open for the sale of milk from May 15 to October 1st. From four to
five nurses are employed with several assistants, and four doctors su-
pervise the weekly conferences, while a great deal of instruction in the
preparation of milk and care of the child is given in houses. Besides
this, there is the nursing care of sick babies. In October the sale of
ruilk is discontinued, and only two conferences are maintained as we are
able to afford only half the time of one nurse. This year we have
had 581 babies enrolled, about eight per cent of the infant popula-
tion. Last spring we unaertook a limited amount of prenatal work,
and we have had about forty-four cases under care. The instruction
was given by the nurse to the mothers in their own homes and the
results have been very satisfactory. Of the thirty-two babies, only two
have been bottlefed.
HEHBIETTA F. THACHEB, President.
ILLINOIS
INFANT WELFARE SOCIETY OF CHICAGO
I, Registration of births does in no way serve us as the starting
point in our work. We have a very inadequate registration.
II. It is estimated that 55,000 babies are born in Chicago annually
and one-half of that number are in need of such instruction
as is given by our Association. The Association is only able
to reach about one-fifth of this number.
III. The work is carried on during the entire year.
IV. The work was started in January, 1911. It is not possible to
tell what effect it has on the infant mortality or morbidity
owing to the lack of accurate vital statistics. It is approxi-
mated that the death rate of infants under two years of age
for the whole city is between 15 and 20 per cent. The death
rate of infants under our care for the past nine months has
been 3.3 per cent.
V. Very close co-operation and during the summer of 1913 five
Health Department Nurses were turned over to our society.
VI. Our welfare work co-operates very closely with all other welfare
activities in the city.
VII. and VIII. Only a small per cent of pre-natal work is possible
owing to the small staff of nurses. It is with a great deal of
regret that the Society has not been able to include prenatal
work, as we believe it is the time when Infant Welfare Work
should begin.
IX The Society conducts 13 Infant Welfare Stations, holding weekly
conferences between doctor, mother and nurse. Milk is not
distributed at the Welfare Station, but is delivered in the
homes under the direction of the Society. Instruction is given
to mothers by the nurse in the home and by the doctor and
nurse at the conference.
An attempt has been made to give class instruction,
but has been found that much more is accomplished by indi-
vidual instruction. The mothers with whom we are dealing
are not prepared to make application of instruction given in
a general way.
372 REPORTS
X. We have a staff of 13 nurses, 1 supervising nurse and 13 doctors.
XI. The work is financed by voluntary contributions. We have a
budget of about $25,000.
After a careful study of the situation in Chicago the following pro-
gram of work has been outlined, which would be necessary to care for
the infant population: 55 Infant Welfare Stations, staff of 20 pre-
natal nurses, a Registry for wet nurses and supervision of boarding
homes.
Such a program would require an annual budget of $110,000.
MINNIE H. AHRENS, R. N., Superintendent.
THE LYING-IN HOSPITAL . AND DISPENSARY
Chicago
The Chicago Lying-in Hospital and Dispensary conforms to all re-
quirements expected of a legitimate institution, covering all branches
of the work. We do not care for the case after two weeks ordinarily,
but should the case need special care it is looked after by our social
worker.
In the last eighteen years the hospital has
1. Careo* for more than 15,000 mothers, with a mortality rate of less
than .001.
2. Given over 180 physicians 6 months' training exclusively in ob-
stetrics.
3. Grounded over 3,800 students in elements of obstetrics and OD-
stetric cleanness
4. Trained over 400 nurses to qualify as obstetrical nurses.
EMMA E. KOCH, R. N., Superintendent.
EMMA MATTHIESSEN CHANCELLOR MEMORIAL MODIFIED MILK
STATION
La Salle
I., II., III. Our work is carried on throughout the year.
IV. It was started June, 1911
It is the only work of this nature in our city.
IX. We have one central welfare station, located in a suitable build-
ing. Weekly conferences between doctor, nurse and mother are held. Our
service includes instruction to mothers at their own homes, and nurs-
ing care of sick babies. We supply milk to those in need. The milk is
delivered upon the nurse's order from a practically certified milk route.
X. We have a medical director, but all physicians of the city are
entitled to privileges, and to hold conferences.
XI. Our work is financed by a public-spirited citizen.
L. B. VAN HOEN, Superintendent.
AFFILIATED SOCIETIES 373
INDIANA
CHILDREN'S AID ASSOCIATION
Indianapolis
Milk-station work of this Association was begun in 1908 with one
clinic, which was located in one of the poorer sections of the city. The
following year three other clinics were established and each had its
own nurse and its physician. The milk at that time was obtained by
the mothers at these stations, but as the work progressed it became evi-
dent that our field was limited to a radius of about eight blocks from
the distributing station and the next problem was the distribution of
the milk directly to the home. At the present time we feel that we
have in many ways ideal conditions for an unlimited extension of
the milk-station work. Our milk comes from a selected tuberculin-
tested herd and after pasteurization by the "holding method" it is
bottled and delivered directly to the homes by one of the milk firms,
which covers the entire city. Our milk is delivered to the home at a
cost of twelve cents a quart to the Association. At present four clinics
are established in different sections of the city, which will be open
the entire year, and our plans call for the establishment of six more
during the summer months. The Central Dispensary is located within
a few blocks of all the car lines of the city, and to this clinic are
brought the scattering cases. In this manner have we solved the prob-
lem of pure milk and its distribution.
The medical phase of the work is covered by a staff of physicians
under a medical director. Four nurses under the supervision of a
head nurse constitute the nursing staff. The city is districted ac-
cording to the number of nurses employed, and the nurse visits in
the home of every child two weeks after its birth return, and in-
structions are given to the mother as to maternal feeding, and the
care of the child and the mother is also advised not to wean the baby
until she has consulted her own physician or has been seen by one ot
the physicians at the clinic. In this way babies have been kept at the
breast and others have been started along the right lines of artificial
feeding. The nurses also canvass their district for older babies and
bring them into the clinic for advice. We reach about 15 per cent of
the infant population in this manner
Our clinics are kept open throughout the entire year, and frequent
conferences or mothers meetings are held in which general instruction
as to the care of babies is given. It has been endeavored to have the
mothers at these meetings ask questions pertaining to their own per-
sonal experience.
The work is financed through the Children's Aid Association, which
spends $10,000 a year, $5,000 of which is appropriated by the city
through the Board of Health and the rest is given by private sub-
scription. Close relationship is maintained with the Social Service
Department of the Indiana University School of Medicine, and the
Fresh Air Mission. Through the latter we are enabled during the
summer months to send our sick babies with their mothers into the
country. Milk and nurses are also furnished to any case upon the
advice of their family physician, who can also retain the supervision
of the feeding independent of the medical staff of the Association.
As yet very little pre-natal work has been done, although the nurses
have been instructed to advise expectant mothers and the Association
will furnish milk to them during the last months of pregnancy.
374 REPORTS
Simple dilutions are used exclusively by the physicians, and all modi-
fications are made by the mothers in the homes under the supervision
of the district nurses. Centrifuged milk can be obtained through the
milk company enabling the physician to use a fat free mixture.
Our work has grown from 198 babies in 1908 to 1025 babies in 1913.
Eighteen deaths occurred during the last year, many of the babies hav-
ing been moribund when first seen.
EUGENE B. MTJMFOED, Chief of Medical Staff.
SUSAN M. KISSELL, Bead Nurse.
CHILDREN'S DISPENSARY AND HOSPITAL ASSOCIATION
South. Bend
I. We use the registration of births to get a line on all the babies
born in the district where our work is done.
III. Our work is carried on during the entire year.
IV. Our work was started in 1909.
Y. We have no official connection with the Department of Health.
VII. We are doing both pre-natal and post-natal work.
VIII. Our instruction in pre-natal work is given by a nurse in the pa-
tient's home. We have just begun pre-natal work, and have
only had ten cases. We do not furnish obstetrical service.
We have had two maternal deaths and one infant death. The
maternal deaths were due in the one instance where a physi-
cian was in attendance to tuberculosis, in the other, a mid-
wife, to a hemorrhage. The infant death was due to asphyx-
iation. Our instructions to mothers are along the line of diet,
open-air exercise, ventilation of sleeping rooms, care of breasts,
importance of breast feeding and of urine tests.
IX. In our post-natal work we have one Welfare Station; in the
summer we have daily conferences between physicians, nurses
and mothers. In the winter we have weekly conferences. Our
work aims to be along prophylactic lines, but we treat dis-
eases when necessary. We distribute, sell or give away milk
according to circumstances.
X. We have four attending physicians and three consultants.
XI. Our work is financed by general subscriptions.
CHARLES E. HANSEL, M. D., Medical Director.
IOWA
CHILD WELFARE COMMITTEE OF THE BURLINGTON CHAPTER
OF THE RED CROSS
The Child Welfare Committee of the Red Cross has been at work in
Burlington since January 16th, 1912. It has now completed its first
full fiscal year.
As the babies have outgrown our age limit of two years, others have
been enrolled to take their places, and we are now in touch with more
babies than we were at the same time last year. Our greatest advance.
AFFILIATED SOCIETIES 375
however, has been in the increased cooperation of the mothers, who
have come to us with a better understanding of what we are trying to
dp for them, and have made great gains in profiting by the instructions
given. Some mothers are like the woman who said "You can't teach me
anything about raising children, I've buried six." As our work consists
mainly in instruction along the lines of feeding and general hygiene,
our greatest success has usually been with the voung mothers with
their first baby.
These meetings are held every Friday afternoon at 3.30 at the Y. W.
C. A. Building, with a nurse and doctor in charge. Records are kept
of the babies' birth, weight, changes in feeding and other items per-
taining to the individual's case. The physician instructs the mother,
after his examination of the child, and calls the attention of the nurse
to any cases that will need special care before the next meeting. Sick
babies are not treated at these clinics, but are referred to the family
or county physician, or a specialist, if the case requires it.
When the people of Burlington are enough aroused to the necessity
for pure milk to insist upon having it, our work will be mucb more
effective. At present, one of our greatest difficulties is in procuring
clean milk for the bottle-fed babies.
Replying to the questions:
I. The birth registration law is entirely unenforced in Burlington,
and I fancy throughout the state.
II. For the above reason we cannot tell what proportion of the in-
fant population is reached by our work. The health officer,
however, tells me that they estimate about 350 births a year,
and we have approximately 30 babies attending meetings at
the welfare station.
III. The work was started January 16th, 1912. We can give no
statistics as yet about its effect on infant mortality.
IV. Our relations with the Department of Health are cordial, but
not organic.
V. We work in harmony with the Charity Organization and the
Visiting Nurse Association.
VI. and VII. We have attempted practically no prenatal work.
IX. and X. We have no nurses of our own the Visiting Nurse does
our work, and six doctors have given their services.
XI. The work so far has been financed by private philanthropy.
MABY P. MCILVAINE, Chairman,
Burlington Chapter of the Red Grossi
KANSAS
THE CHRISTIAN SERVICE LEAGUE OF AMERICA
Wichita
The following report summarizes the work of the League in caring
for babies under one year of age, for the six years ending May 31, 1913 :
Number of babies received, under one year of age 155
UNDEB ONE MONTH
Number of babies received under one month 81
Number of babies who have died in the care of the League, and who
were under one month when received 12
376 REPORTS
Number of babies who died while with foster parents, and who
were received as wards of the League before they were one
month old 3
BETWEEN ONE AND THREE MONTHS
Number of babies received 38
Number of babies who have died in the care of the C. S. L., and
who were between one and three months old when received 5
Number of babies who died with foster parents, and who were re-
ceived as wards of the C S. L. before they were three months
old 2
BETWEEN THREE AND Six MONTHS
Number of babies received between three and six months old 20
Number of babies who have died in the care of the C. S. L., and who
were between three and six months old when received 1
BETWEEN Six MONTHS AND ONE YEAB
Number of babies received between six months and one year old 16
All children received after they were six months old are still living.
Two of the one hundred and fifty-five above mentioned were placed in
the Wichita Hospital for treatment, where they died. Eleven out of the
total of deaths were pronounced by attending physicians as unpre-
ventable. If circumstances had not seemed to compel us to receive in-
fants under one month old, we would have had very few deaths. Had
we received none tinder three months old, our death rate would probably
be less than six per cent.
All of the one hundred and fifty-five babies, wards of the C. S. L.,
except the number who have died as recorded above, are still living.
They are well and healthy, without exception. Quite a number of them
are now in their sixth and seventh year.
We are quite sure that any other society could do as well as we have
done during the past if proper care were exercised and a proper effort
put forth. We believe that many of them who have had a very large
death rate have probably endeavored to do their best to preserve the
lives of the babies ; but either through lack of proper methods, lack of
knowledge or lack of adequate financial support, they have failed.
The statements which have been made by eminent physicians that
only a very small per cent, if any, of abandoned infants ever live to be
two years of age will not hold true with wards of The Christian Service
League. Not only are these little ones living whom we have taken and
cared for during the tender period of the early months of their existence,
but they show as good prospects of living to maturity and to a ripe old
age as do other children of the community.
GEORGE L. HOSFORD, General Superintendent
KENTUCKY
THE BABIES' MILK FUND ASSOCIATION OF LOUISVILLE
I. The Registration of births has been of little service although an
attempt was made to have all births recorded by City Physi-
cians referred to the Association on mailing cards provided for
the purpose.
AFFILIATED SOCIETIES 377
II. In 1912, the total registration of the Babies' Milk Fund Associa-
tion was about 18 per cent of the birth registration that year.
III. The work is carried on during the entire year.
IV. The Milk Fund Association was organized in 1908. According
to a statement in the report of the Department of Health for
1912, there was a reduction of 50 per cent in deaths from
diarrheal diseases that year. There are no statistics available
to show the effect of the work except a steadily decreasing
death rate in the records of the organization.
V. We have no connection with the Department of Health except by
close co-operation.
VI. Affiliation with all kindred welfare work.
VII and VIII Systematic pre-natal work has been started recently
in connection with free obstetrical service. Instruction is given
by physicians at the obstetrical clinic where the expectant
mothers are required to report at intervals, and by nurses
who visit in the homes.
The free obstetrical clinic, opened September, 1913, has not been
in operation long enough to furnish useful figures. The plan
of the clinic is to give thorough prenatal instructions, and care
with adequate and expert obstetrical service at the time of
delivery and postnatal nursing for ten days.
IX. The postnatal work includes the sale and free distribution of
certified milk, also laboratory modifications when necessary;
nursing care of sick babies, weekly conferences between doctor,
mother and nurse, individual instructions in the home and
demonstration to groups at the Stations.
The Association maintains five Stations.
X. The medical staff consists of a medical director and five station
physicians with an alternate for each; the nursing staff, of
a supervisor and six nurses.
XL Our work is financed by appropriations from City Council and
Fiscal Court, and private subscriptions.
FULTON, Medical Director.
MARYLAND
COUNCIL MILK AND ICE FUND
Baltimore
I. We supply the milk, ordered by the visiting nurse or physician.
III. Our work is carried on during the entire year.
IV. We started in the summer of 1895. Do not keep an exact record
of the mortality. Consequently cannot give statistics.
V. Our work is conducted independently, but
VI. We co-operate with all Associations doing welfare work.
VII. Our activities include both prenatal and postnatal work.
VIII. The prenatal work is done by the Visiting Nurses or Baby Milk
Association, who co-operate with us, whenever a case is
reported.
378 REPORTS
IX. The outline followed in the postnatal work, is observation of the
child, and insistance of the proper feeding, until child is two
years old. As many mothers as we can influence are requested
to bring their babies to the weekly conferences at the Babies'
Milk Fund Stations, where the conferences are held with
doctor, mother and nurse. The orders for the milk are sent
by the physicians of the various hospitals, as well as from
attending doctors.
XI. The Federated Jewish Charities, appropriate the necessary funds
to carry on this work. The distribution is about 44,000 quarts
of milk per annum.
MBS. ISIDOBE ASH, President.
MARYLAND ASSOCIATION FOR STUDY AND PREVENTION OF
INFANT MORTALITY
("Babies' Milk Fund Association of Baltimore* 7 )
February 1st, to September 1st, 1913
(ITrora beginning of present fiscal year, for seven months only)
I. The Babies Milk Fund Association receives its prenatal calls
directly from the obstetrical departments of the leading hos-
pitals. We also receive calls from expectant mothers directly,
neighbors and the Charity organizations and other associations
engaged in welfare work.
CALLS REFERBED
Johns Hopkins Hospital 783
Mercy Hospital 394
Maryland General and Maryland University
Hospitals 78
Federated Charities 31
Instructive Visiting Nurses Association 6
Tuberculosis Nurses 6
Neighbors and Patients. 54
1,352
II. There are approximately between 15,000 and 17,000 babies born
yearly in Baltimore, and of this number we have reached from
February 1st, 1913, the beginning of our fiscal year, to Septem-
ber 1st, 1913, (7 months), 3,930 cases, a decided increase over
the year 1912, and about 20 per cent of the total infant popula-
tion.
III, This work is carried on throughout the year, three temporary
nurses being added for the summer work only.
IV. The Babies Milk Fund Association was organized during 1904 a
full report of the organization is given in "Report of The
American Association for Study and Prevention of Infant Mor-
tality, October, 1912."
V. The Babies Milk Fund Association has no connection with the
Board of Health, except co-operative.
AFFILIATED SOCIETIES 379
VI. We have hearty co-operation with all agencies engaged in wel-
fare work, physicians, hospitals and dispensaries, and the
various nursing organizations.
II. The Association has been engaged in prenatal work since October,
1910, first in connection with the Johns Hopkins Hospital ob-
stetrical department, and since February, 1911, we have
worked in connection with the four leading hospitals in both
prenatal and postnatal work.
OUTLINE OF PBENATAL WOEK.
II. Instruction general, both social and medical, by doctors and
nurses in classes, and in their own homes.
Work has been carried on for two years, beginning first with the
postnatal work from the Johns Hopkins Hospital, in 1910, and
in February, 1911, we started our prenatal and postnatal work
from the four leading hospitals.
About 4,000 mothers have been reached.
We see that the patient gets the proper care. We ourselves do
no obstetrical work except in emergency cases.
We have found that at least 80 per cent of our babies are breast
fed, and the other 20 per cent either have been partially
breast fed or altogether bottle fed. (See Table No. 3.)
POSTNATAL WOBK.
IX. When the baby is ten days old, and after it has been discharged
by the hospital service, we visit the mother and child. Our
visting doctor makes if possible a physical examination; the
weight is taken and the chart started. From then on we see
the baby as often as possible either at home or welfare station
until it is a year old, when the doctor makes a second visit
and a physical examination, and the chart is discharged. Of
course this does not mean that the baby is discharged alto-
gether, as we encourage the mother to keep in close touch with
us until the child is at least 3 years old.
X. We "have ten Welfare Stations. We have weekly conferences
between the mothers, doctors and nurses, and also instruct the
mothers in their own homes.
The staff includes:
The Medical Director, Dispensary Physician, five Conference
Physicians, one Supervising Nurse and eight Field Nurses.
XI. Our work is financed by private subscriptions, and one annual
appropriation from the Thomas Wilson Sanitarium.
380
REPORTS
TABLE No. 1
PRENATAL CASES REFERRED
February 1st, to September 1st, 1913
No.
H
((
Station
1 2Kfi
Hospitals
Mel. Neighbor
Mercy Univ and
J. H. H EL Md. Gen. Pts.
197 51 ... 1
270 60 ... 4
11 83 1 16
41 18 45
70 132 32 23
160 32 ... 3
33 9 ... 4
1 9 ... 3
C.O.S. V.N.A.
2 2
3 1
12
3 3
4
4
3
T.B.N.
1
1
4
9
. . 334
3-8 . .
. . 116
4
. . 116
5
. 260
6
.. 199
7
.. 50
9-10... ,
21
Total.... 1,352 783 394
Prenatal S27
Postnatal 154
Left city 46
Wrong address 199
Did not want to be visited. . 9
Died before rfd 1
Premature before rfd 3
78
54
31
6
14
Miscarriage before rfd .....
Still born before rfd ...... 12
Mistaken diagnosis ......... 22
Repetition ................ 37
Could not visit ............. 28
Total ................... 1,352
AFFILIATED SOCIETIES
381
ft-
00 -3 C5 OT 14*- CO tO M
5
o
Mothers visited before
confinement
TABLE No, 2.
STATISTICS
Approximate Number of Births in the City (year 1912) 15,000
February 1st, to September 1st, 1913
Number of Mothers. Number of Infants.
e
^ M H-
O OS h* O5 CO M H-
^tf^OOCfc-^<3P^CN
^
Ot
14^
Lost
sigHt of
before
confinement
- oi
O
Died
before
confinement
D
to 2 01
Survived
Delivered
rfx QJ 5i
5"
Dfq
CO
Died in
or after
confinement
CO
O5
*
Living at end
of 1st, mo.
=1
^
I
sf
B
fS
r+
s
Died during
1st, mo.
!;!;::: !S
00
Living at end
of 1st, mo.
.* i i . i i ; co
GO
Died during
1st, mo.
.* I ! . I *. ' GO
s
Still born
i * ; i i r * S
ff 5. 5* i SI
M Il : B
QJ *p
Miscarriages
382 REPORTS
TABLE No. 3
PRENATAL
Babies Being Followed And Their Diet
Carried from 1912. 380
Delivered since February 1, 1913 565
Still born 34
Moved-lost 109
Left city 60
Died 60
Miscarriage 13
Died 1 month, premature 3
Died full term 24
Balance followed 262
642
Postnatal followed 154
Total babies followed 796
Breast fed 540
Bottle fed. 158
Breast and bottle 98
796
Discharged 1 year in good condition 371
M. FRANCES E^TCHBEBGEE, B. N., Superintendent.
MASSACHUSETTS
MASSACHUSETTS BABIES' HOSPITAL
Bo at on
(Formerly Massachusetts Infant Asylum. Founded 1867)
A Society Combining Hospital Care with, the Placing: at Board in
Private Families of Well Babies whose Parents are
Temporarily Unable to Care for Them
Forty-six years ago a group of philanthropic people in Boston, be-
lieving that the infant mortality among the babies cared for by tne
State was too high, formed themselves into a society which had for its
object the reduction of infant mortality. It was founded with these
two great principles in mind: That a family is the best place for a
baby, and that breast milk is the best food.
They began by placing well babies at board in selected private
families, and by keeping the sick babies in a house hired in the suburbs,
AFFILIATED SOCIETIES 3S3
where they were wet-nursed by foster mothers. Bach foster mother
having one other baby besides her own to nurse. Later a house was
built especially for these sick babies.
A good many years have passed since then and many changes made,
but the two great principles of the work are the same.
At the present time the babies at board are visited every week, and
sometimes oftener by trained nurses.
Meetings for the boarding women are held once a month, and talks
are given on the physical and ethical care of the baby.
The old house has been enlarged and reorganized, and now is a hospi-
tal especially equipped for the study and treatment of infant diseases.
The hospital gives a special course to graduate nurses, and at the
present time is affiliated with one hospital of good standing. It also
has a course for nursery maids.
Clinics are held in the out patient department to which mothers
bring their babies for treatment. At the same time they receive in-
struction in preparing milk and the general care of the baby.
A directory for wet-nurses which was established nearly three years
ago, is carried on in connection with the hospital. Its object is to
supply mother's milk to desperately sick babies and to encourage the
natural feeding of babies. A thorough physical examination and
Wasserman test is made on each wet-nurse.
Every baby admitted for boarding care is examined at the hospital,
and if necessary is kept in the hospital until in fair condition to be
placed at board. They are examined again at the hospital before going
home.
An effort is made to keep in touch with the family while the baby is
under the Society's care. When the conditions are removed which made
it seem necessary to take the baby out of its own family, the baby is
returned home. The mother is given a slip on which the milk formula
and rules for the care of babies is printed also the address of the nearest
milk station. A return post card is sent to the same milk station with
the request that this Society be informed if the baby is or is not under
their care. If not, other arrangements are made to place the family
and baby under proper supervision.
Report November 1, 1912, to November 1, 1913.
Applications 851
Number in care of Society Nov. 1, 1912 115
Admitted during year 421
Total 536
Discharged 344
Died 80
ALICE M. CHENEY, General Secretary.
MASSACHUSETTS MILK CONSUMERS' ASSOCIATION
Boston
An Association Formed to Unite Consumers in Obtaining; Efficient
Inspection and a, Pnre Milk Supply
The Massachusetts Milk Consumers 7 Association believes that in spite
of its failure to secure the legislation which is its object nevertheless
considerable progress has been. made. This year as never before the
384 REPORTS
candidates for the Legislature have appealed to the consuming public
to note their record and their pledges in this most important matter
many of those who had voted for the Consumers' Bill in the past using
in their campaign for election to the General Court this year the let-
ters of approval previously sent them by this Association.
The Association has continued its active campaign of education all
over the State. It has sent its officers to speak before Granges, Wom-
en's Clubs, Pure Food Fairs, Labor Unions and other gatherings. It
has distributed literature in large quantities to newspapers and individ-
uals during the past fourteen months over 61,000 letters and 35,000
pieces of literature have been sent out. The cooperation of the press
has been an invaluable and constant help. The exhibit prepared for
the XV International Congress on Hygiene and Demography has been
touring the State for the past year together with the exhibits of the
State Board of Health and those of other public and private organiza-
tions. Beside this the Association has just got up with the help of the
National Committee on Child Welfare Exhibits a small traveling exhibit
to lend to any Massachusetts people desiring it. They confine them-
selves to Massachusetts for the allusions are necessarily local because
its purpose is to enlist interest and to arouse enthusiasm to carry out
their measure, namely, to give to the State Board of Health the power
to protect the health of the people of Massachusetts by safeguarding
the milk supply. The bill would protect not only the lives of the con-
sumers, but the pocketbooks of the clean producers who form the great
majority of the farmers of Massachusetts and whose product is at
present most seriously injured through being contaminated by the
admixture of the dirty milk supplied by the few careless producers in
Massachusetts and other States. Out-of-State milk peculiarly requires
a system of State- wide inspection for its control.
Progress has been made in spite of the failure of the Governor and
Legislature to grant the people the protection they need Even the
opponents of the Association acknowledge that much good has been
accomplished by its work and that the dairies are noticeably cleaner
as a result of its compaign. Perhaps some of the reduction of infant
mortality during the three years of its existence may be due to the
labors of this Association. The rate of infant mortality in Massachu-
setts has been reduced from 134.2 in 1910 to 117.8 in 1912. The deatfis
under two years from diarrhea and enteritis are but 85 per cent of
what they were in 1910. They then numbered 3,744 whereas in 1912
the number was only 3,180
The most serious opposition to progress comes from the Master of
the State Grange, a small county politician, and from the State Board
of Agriculture, which is a State Board only in name, consisting rather
of an aggregation of 40 units chosen mostly by the many small agri-
cultural societies of the State, many of whom exist simply to get the
bonus paid by the State to agricultural bodies.
About 2,000 producers have signified their approval of the Consumers*
Bill.
Some time this opposition will be overcome, for it is merely carried
on for self aggrandizement, and it is only a question of time before the
people assert themselves in order to save the lives of their children.
The Association will work until this their aim is accomplished.
ELIZABETH PUTNAM (MBS. WM. LOWELL PUTNAM).
AFFILIATED SOCIETIES 385
THE MAVERICK DISPENSARY
East Boston
FOB THE YEAE ENDING SEPXEMBEB 30, 1913
I. Boston Board of Health sees every case in certain districts ; gives
literature and advice and refers, if desirable, the case to
Milk and Baby Hygiene Association and the Maverick Dis-
pensary.
II. You are referred to the report of the Milk and Baby Hygiene
Association, of which we have one station as part of our
work in East Boston.
III. Our work is carried on during the entire year.
IV. October 1st, 1912, in the present form and place. We can refer
to Milk and Baby Hygiene Association report.
V. The Board of Health nurses refer cases to us.
VI. Close cooperation. In six months we have referred to other
agencies 219 patients (22 per cent) . They have referred to us
276, cases or 28 per cent.
VII. Our prenatal work is carried on as follows :
VIII. (a) Physician trained in obstetrics registers cases, examines
and instructs them. Two specially trained expert nurses
visit at intervals of not over ten days in the homes of the
patients.
(b) This work was begun February 1st, 1913.
(c) Eighteen cases have been completed.
(d) We do provide obstetrical service.
(e) We have no figures, but consider our results good. We have
had no maternal mortality and but one infant death, or
5% per cent.
IX. Postnatal work :
An obstetrically trained physician makes 3 or 4 visits as may
be necessary. The district nurse visits for two weeks. There
is but one station in East Boston. Physician and nurse in-
struct in the home and then patient is referred to Milk and
Baby Hygiene Association later, station being at the Maverick
Dispensary. Weekly conferences of mothers with their infants
are held at the Dispensary by the nurse and conference physi-
cian. Sick babies are referred to regular dispensary clinics.
We have a milk station in the building
X. Our staff consists of the physician in charge of the Dispensary
and the Milk Station. He is also conference physician. We
have besides an obstetrician and assistant obstetrician. We
have a nurse on the infant work and in the summer she has
an assistant. We have also prenatal work which takes part
of the time of two district nurses.
XI. Our patients in obstetrics pay a large part of their services.
In the Milk and Baby Hygiene no charges are made.
The Maverick Dispensary maintains a general clinic including den-
tistry week days, throughout the year. A summary of the work for
one year:
386 REPORTS
VISITS BY PATIENTS AT DISPENSARY SEPT 1, 1912, TO SEPT. 1, 1913
All Patients New Patients
Medical 1,334 772
Surgical 1,467 668
Dental 389 216
Eye 304 146
Skin 67 33
Obstetrical .... ... ... 43 31
Throat 40 18
Orthopedic ... . 3 2
3,697 1,886
Daily Average 12 6
Further classification for six months shows the predominance of chil-
dren and nationality of our patients:
Six MONTHS MARCH 1 TO SEPT. 1, 1913
Children 712 73% Italian 313 32%
Women 186 19% Russian 264 27%
Men 73 8% Others 394 41%
Total New 071 100%
971 100%
Our relation with other agencies is indicated as follows :
276 (28%) were referred by other agencies
219 (22%) were referred to other agencies
Our policy of referring cases for consultation or treatment to other
agencies or hospitals, when more accurate or intricate methods are
needed than our equipment at present provides, or where surgical care
of considerable gravity is required, we consider has resulted in much
benefit to our patients. We are inclined to congratulate ourselves that
we have nothing so far to regret from attempting more than our lim-
ited equipment would justify. Whereas, we have been able to adviso
many where their graver ills may receive the most skilled treatment.
A brief financial statement may be of interest. Total expenses, one
year, $3,325.33. (This includes a large amount of permanent improve-
ments ) Total receipts from patients, $742.57.
A one-month statement September, 1913. Total expenses, $82.70;
total receipts from patients, $78.74.
A. B, EMMONS, 2ND, Physician-in-CMef, Maverick Dispensary.
COMMITTEE ON INFANT SOCIAL SERVICE, WOMEN'S MUNICIPAL
LEAGUE OF BOSTON
For report, see pages 187-190,
AFFILIATED SOCIETIES 387
THE MILK AND BABT HYGIENE ASSOCIATION
Boston.
I. Before the City of Boston created the Division of Child Hygi-
ene, the Milk and Baby Hygiene Association received copies
of birth registrations from the Registration Department. Our
nurses visited these babies as far as possible. Now such babies
as need care are referred to the Milk and Baby Hygiene Asso-
ciation by the Board of Health nurses who visit every new-born
baby. The following table shows how the 2,500 babies under
care from January 1 to August 16, 1913, were referred to the
Association :
Referred by Board of Health Nurses 294
" " Baby's mother or neighbor 1,051
" Milk station nurses 354
" Instructive District Nursing Assn Ill
Private physicians 284
" Hospitals 247
" Settlements 67
" Associated Charities 32
" " Other agencies 64
Total 2,504
II. Nineteen thousand babies are born yearly in Boston. During
1912, 3,026 were cared for by the Milk and Baby Hygiene
Asociation. For 1913 it is estimated the number will be 4,000,
an increase of 33 per cent over 1912, and over 20 per cent of
the total infant population.
III. This work is carried on throughout the year, each welfare sta-
tion being taxed to the limit of the nurse's capacity. During
June, July, August and September, 1913, there were added
four temporary nurses for summer work only.
IV. The Milk and Baby Hygiene Association the only agency in
Boston combating infant mortality through establishing milk
stations with adequate nursing service, was started in 1909.
The fourth annual report, published in May, 1913, shows the
following steady growth :
1910 1911 1912
Number of babies under supervison at
beginning of year 738 1,079 1,221
Number of babies supervised during
year 1,870 2,827 3,026
Number of visits by babies at confer-
ence with doctor 10,847 10,972 11,451
Number of home visits made by nurses 28,605 32,156 38,659
Of the 3,026 babies cared for during 1912, 951 were breast-
fed, 1,045 partially breast fed and 831 bottle fed.
After three years' experience in medical service of this
Association we are now ready to offer evidence of a meas-
urable reduction in infant mortality as the direct result of
our preventive and educational work. The results pre-
sented are based on statistical evidence prepared by a rec-
ognized expert, Dr. W. H. Davis, Vital Statistician of the
Boston Board of Health.
388 REPORTS
These results are:
1. That the death rate (72.25 per 1000) among babies under
one year of age admitted to the supervision of the milk
stations in 1911 was 25 per cent below the Boston in-
fant death rate corrected for corresponding numbers,
ages and food.
2. That this reduction of 25 per cent was secured with
babies whose physical condition was so much below
the average Boston baby that their death rate during
the first months of supervision was more than 50 per
cent higher than the Boston infant death rate among
babies of corresponding numbers, ages and food.
3. That the death rate of the bottle-fed babies admitted to
the milk stations in 1911 was reduced 31.76 per cent
below the corresponding Boston rate.
4. That the results in the reduction of infant mortality were
in proportion to the length of time the babies were
under our supervision.
5. That the number of deaths due to gastro-intestinal and
respiratory diseases, respectively, among babies under
our care, indicates the milk-station methods are nearly
as effective in combating respiratory as gastro-intes-
tinal diseases, these being the two chief classes of
diseases causing death during the first year of life.
A fuller statistical report is in progress of compilation by
our medical committee.
V. The Association cordially co-operates with the Boston Board of
Health of which it is quite independent. From January 1 to
August 16, 1913, 294 babies were referred by the Division of
Child Hygiene to the Association The welfare stations of
the Association are used in many cases daily by the Board
of Health nurses. The Association, after conferences with
the city authorities, laid before the City Council a petition
urging that the nurses in the Division of Child Hygiene be
doubled for the summer months of 1913. As a result the
city increased its staff of nurses in the Division of Child Hy-
giene from nine to eighteen.
VI. There is cordial co-operation with all agencies of welfare work
in the city : with private and district physicians hospitals and
dispensaries, the Instructive District Nursing Association, the
children's agencies, relief societies, day nurseries, settlements.
VII. and VIII. The Association is just now engrossed in working out
a plan of pre-natal work. A large amount of pre-natal care is
being given by the nurses of the Instructive District Nursing
Association. It is planned to tie up this work with the
milk stations, so that there wiU be continuous care for all pre-
natal cases. A careful study of the results of pre-natal work
is being made by the Milk and Baby Hygiene Association.
Miss Mary Beard, director of the Instructive District Nurs-
ing Association, has an advisory position on the staff of the
Milk and Baby Hygiene Association, and there is extremely
intimate cooperation between the two associations.
IX. Twelve welfare (or milk) stations, from which inspected pas-
teurized milk is daily distributed at cost from 8:30 to 9:15
A. M. Constant visits are made by the nurses to babies 7
homes and have resulted in the teaching of 403 mothers to
AFFILIATED SOCIETIES 389
modify milk at home, an increase of 400 per cent in twelve
months. General instruction in baby hygiene and home sani-
tation is given. The conferences are held weekly or more
often at every welfare station, at which the doctor and nurse
meet mothers with babies. Babies are weighed and each
mother and child individually sees the physician for advice
and help. All really sick babies are referred to physicians,
hospitals or dispensaries. The nursing care of sick babies is
done by the Instructive District Nursing Association.
X. The staff includes the medical director, paid, and fourteen vol-
unteer conference physicians ; one supervising nurse and thir-
teen field nurses, all paid.
XI. The Association is without endowment or permanent fund. It
receives no grant from the city or State. It is entirely sup-
ported by annual contributions and donations.
GEORGE E. BEDINGEK, Director.
SOCIETY FOR HELPING DESTITUTE MOTHERS AND INFANTS
Boston
I. The registration of births does not serve as the starting point
for our work. Our work begins with the application of tne
mother to us.
II. The proportion of infant population reached by our Society
varies ; in 1910 there were 374 infants ; in 1911, 397 ; in 1912,
323.
II. This work is carried on throughout the year.
IV. The Society for Helping Destitute Mothers and Infants was
started in 1873 at the New England Hospital. We have no
exact statistics, but it is seldom that an infant dies whose
mother is under our care.
V. We have no connection whatever with the Department of Health.
VI. There is cordial co-operation with other charities in Boston,
almost all sending us cases, and we belong to the Associated
Charities.
II. For the first years when we were associated with the New Eng-
land Hospital our Society included pre-natal work in its activ-
ities, but we rarely do this now.
II. Our pre-natal instruction, what there is of it now, is given en-
tirely through individual friendship, not in classes. Some
thousands of mothers have been reached in this way, al-
though we do little of it now. We do not provide obstetrical
service.
We cannot give figures regarding breast-feeding, but every
mother is encouraged and assisted, if necessary, to nurse her
infant through the first summer.
IX. We have no welfare stations. Our visiting is done by workers
from headquarters, who give instruction wherever needed.
When necessary there are conferences between the doctor and
the mother in the mother's home, where she is given instruc-
tions and educated in the proper care of the baby. We do
not sell milk, but have often given it.
390 REPORTS
As our work is so different from other work for infants,
it is difficult to give statistics. A large proportion of our
mothers are employed at domestic service in different parts
of New England, the infant being received with the mother.
We usually hear from these mothers the first two or three
years after they have been settled thus, but we cannot be
sure whether each one is in the same situation after that,
although often they come back to see us. Up until about
thirty years ago a large number of our mothers had infants
placed out to board, which necessitated almost daily visits,
particularly in August and September. We made a change
in this respect, however, and we now arrange that each
mother shall keep her infant in her personal care. We never
place an infant at board except temporarily, in case of the ill-
ness of the mother We feel that this is much the best plan,
and that a child in the mother's care is much more likely to
live.
X. There are three doctors on our Council and two consulting phy-
sicians. We have no visiting nurse.
XI. Our work is financed through private subscriptions chiefly. We
have a small income from legacies
L. FBEEMAN CIABKE, Sewetary.
MICHIGAN
BATTUES CREEK SANITARIUM TRAINING SCHOOI/ FOR NURSES
The Battle Greek Sanitarium Training School for Nurses as the name
implies is purely a training school, yet we are trying to bring our train-
ing up to the highest standard and have in it practical work in caring
for the infants.
We have affiliated with a Children's Hospital in Chicago, where each
nurse gets four months of practical work.
In our obstetrical ward, which is rapidly growing in favor, patients
coming from many parts of the United States for care, several weeks
and months sometimes before confinement, the mothers are given prac-
tical instruction in caring for her baby
They are taught how to bathe and dress the baby, how and when
to feed them, breast-feeding being strongly emphasized, and how to de-
tect symptoms of approaching illness.
We have also in connection with a dispensary a visiting nurse, who
goes into the homes of the people obtaining the mother's confidence,
though helping in some case of illness perhaps or otherwise relieving
suffering and teaching them how and why they should keep their chil-
dren clean, how to prepare wholesome food and the necessity of venti-
.lation.
Here we come in touch with expectant mothers, and by giving free
treatment and nursing for a week after confinement they get the pre-
natal as well as the postnatal care
COKA MOESE, Superintendent.
AFFILIATED SOCIETIES 391
BABIES' MILK FUND ASSOCIATION
Detroit
I. Very small extent. Is supposedly done by Board of Health.
II. Probably in one way or anotber 7 per cent or 8 per cent of tbe
infant population is reached.
III. Our work is carried on during the entire year.
IV. Our work was started in June, 1911. We believe we have di-
minished our morbidity and mortality in the districts where
we have been working. Cannot give statistics except that our
last annual report shows mortality rate of about 4 per cent of
the babies supervised by us and infant mortality of entire
city is gradually diminishing.
V No definite connection with the Department of Health.
VI. Our work is closely related to work of Visiting Nurse Associa-
tion and Associated Charities and Michigan Children's Home
Society.
VII. and VIII. Prenatal work has been temporarily abandoned owing
to impossibility of getting physicians to take charge of ob-
stetric dispensaries.
IX. We maintain five stations in our postnatal work
Instruction is given in nursing care, general instruction,
which includes hygiene of mother and baby, sanitation, feed-
ing, clothing, etc. Milk instruction, which is the demonstra-
tion of the formula for bottlefed babies and friendly visits
of inquiry.
Conferences between doctor, mother and nurse are held tri-
weekly ; plan includes instruction of mothers in their own
homes and nursing care of sick babies.
The sale of milk has been discontinued. Milk is furnished
free only to those cases which are recommended by some
other social agency than our own.
X. Our staff consists of one medical director and four assistant
doctors ; one supervising nurse and five other nurses from the
staff of the Visiting Nurse Association.
XI. Our work is financed by private subscriptions.
XII. The number of babies reached in districts where we are work-
ing has greatly increased, but we have not felt it wise to ex-
tend our work into new districts with the funds at our dis-
posal. We feel that our work is constantly becoming better
systematized and more effective,
ZOE LA FORGE, Supervising 'Nurse,
VISITING NURSE ASSOCIATION
Detroit
We affiliate closely with the Babies' Milk Fund Association, and the
greater part of our baby-saving work is done through that organization.
Our staff nurses are employed by them, and in the course of time we
hope to have every member profit by the experience such cooperation
affords.
392 REPORTS
The Visiting Nurse Association provides obstetrical service. During
the last year we cared for 610 cases. Most of the babies were breast-
fed. We are now planning a system of prenatal instruction as part of
our obstetrical work, and the Babies' Milk Fund Association will have
charge of the postnatal instruction.
The staff of the Visiting Nurse Association consists of 18 nurses, 14
of whom are supported, and supervised by the Association; 2 by the
Detroit Society for the Study and Prevention of Tuberculosis. The
entire time of 4 nurses is given to the work of the Babies' Milk Fund
Association and one to the work of the Jewish Institute Dispensary.
Weekly meetings for the purpose of discussing problems which arise
in the work of the two societies are held by a joint committee of the
Visiting Nurse Association and the Babies' Milk Fund Association.
These meetings have proved an efficient means of preventing overlap-
ping and duplication of work.
LYSTEA E. GBETTEE, R. N., Superintendent.
CHARITY ORGANIZATION SOCIETY
Grand Rapids
We cooperate with the Baby Clinic conducted by the Blodgett Home
for Children in the care of infants and the instruction of mothers, doing
no such work ourselves excepting incidentally in connection with our
regular visitors' work.
EVELYN GAIL GABDINEE, Secretary.
CLINIC FOR INFANT FEEDING OF THE D. A. BLODGETT HOME
FOR CHILDREN
Grand Rapids
I. Bach day we receive from the Board of Health through the
mail the names and address of the births registered the day
before. To these we send our circular on "Care and Feeding
of Babies," which includes the announcement and invitation
to our clinic,
II. Not more than one-third of the babies are reached through our
clinics, but we feel that we reach a larger percentage through
the follow-up work in the homes and the education given
through the press, and talks given at various times in school
centers, literary societies, etc.
HI. Previous to this year our work has been carried on during the
four summer months. We plan, this year to continue the
entire year.
IV. The Board of Health finances, under our management, the equip-
ment and running expenses of one clinic station, also the
services of one nurse.
V. We cooperate with all the Welfare Societies. They report sick
and neglected babies who have no family physician in attend-
ance.
VI. Owing to inadequate nursing service we have not been able to
outline any plan for prenatal work. We have furnished milk to
AFFILIATED SOCIETIES 393
expectant mothers and given instructions to many. We nope
to include' this line of work later on.
VII. Our work does not include obstetrical service.
VIII. We have two Welfare Stations. Central Station, situated in a
downtown district, accessible to several districts is the head-
quarters for the general management. The West Side Station
is held in a room equipped for the purpose in St. Adelbert's
schoolhouse, in the heart of a large Polish settlement.
IX We hold two clinics each week in each station. Doctors and
nurses are in attendance. The mothers bring sick and well
babies to each clinic. Each baby is weighed and prescribed
for. and the mother is given talks by the doctors and nurses
on the care of herself and baby. The nurse follows the case
into the home to see that the doctor's orders are carried out,
to give bed-side care to sick babies and to teach preventive ill-
ness in the care of milk, fresh air and cleanlines.
We teach home modification chiefly. We do some modifica-
tion at the Central Station for special cases, and furnish milk
free of charge where the family cannot furnish it.
Natural feeding is our greatest effort. This includes the
proper care and feeding of the mother so as to give an abun-
dant milk supply.
X. The working staff consists of three nurses and four doctors,
Each doctor has an assistant. We report our eye, ear, nose,
throat and surgical work to specialists, who do this work
free of charge in their office or hospital as required.
XI. Our work is financed by private contribution. The Chamber of
Commerce has paid the salary and carfare of one nurse for
four months each year.
VIOLET LOVE HILL, (MBS. ROBT. G. HILL),
Superintendent of Clinic for Infant Feeding^
MINNESOTA
COMMITTEE ON INFANT WELFARE, DULUTH CONSISTORY,
SCOTTISH RITE MASONS
Duluth
I. Registration of births serves as a starting point for our work
in enabling us to locate the infants In the different districts
and to ascertain whether they were taken care of by a physi-
cian or midwife.
III. Our work is carried on during the entire year.
IV. The work was started in the year of 1911. We are unable to
give statistics for the reason that the Department of Health
has not completed the compilation of the infant mortality
statistics.
V. We have no connection with the Department of Health, except
that we distributed inspected milk at one of the milk sta-
tions, which was located at the Masonic Temple during the
summer months.
394 REPORTS
VI. We are not affiliated with other welfare work in the city, but
do cooperate with them as much as possible.
VII., VIII. and IX. Our work is principally confined to postnatal
work.
The general plan of our postnatal work is as follows :
Our welfare station is located at the Masonic Temple.
Character of instruction given is infant feeding, general in-
fant hygiene and the urging of maternal nursing.
During the months of June, July, August and September
we had semi-weekly conferences between doctor, mother and
nurse.
Our work includes instruction of mothers in their own
homes, and we also have in one of the local hospitals a ward
for sick babies, which is in charge of a special nurse. The
ward is maintained by the Scottish Rite Masons. It also in-
cludes during the months of May, June, July, August and
September, distribution of inspected milk at 7 cents a quart
to those who are able to pay for the same. However, to tbrose
who are unable to pay the milk is distributed free of charge
at the expense of the city.
X. We have one doctor on our staff during the summer months
and one nurse during the entire year.
XI. The work is financed by the Scottish Rite Masons.
E). HEIKKILA, Consistory Nurse.
INFANT WELFARE SOCIETY
Minneapolis
1913
The Infant Welfare work for the past year was conducted along the
following lines :
III. Three fully equipped consultation stations were maintained all
the year round. The stations are located in Settlement
Houses, which in this city are located in the zones where
the infant mortality is the highest. A physician and full-time
nurse are in charge of every station.
All stations are equipped with milk depots. Home modi-
fication of milk is taught as much as possible. Most of the
mothers attending pay for certified milk.
The organization has established a central down-town sta-
tion to which nurses report and from which all literature and
supplies are sent out. A paid secretary is daily in attend-
ance.
A ladies' auxiliary is in the process of forming This body
will be responsible for the maintenance of the stations.
The organization is also planning to establish a baby reg-
ister for the entire city. This is to be conducted through the
central downtown office. Monthly mother's meetings are held
throughout the year, and at stated intervals meetings are held
for the expectant mothers, and form a part of the prenatal
program carried on by the organization. The registration of
births up to the present time has not served as a starting
point for the work. Probably one- tenth of the infant popula-
tion is reached by the organization.
AFFILIATED SOCIETIES 395
The effect on the infant mortality through the efforts of
this organization have heen considerable. No accurate sta-
tistics are at present available, but will be at the end of this
year.
V. and VI. The connection with the Department of Health is not
as intimate and is not as satisfactory as it could be. The re-
lation of the work of this organization with other welfare
work of the city is very intimate and splendid cooperation
exists.
VIII. and IX. The Society conducts both prenatal and postnatal work.
Prenatal work has been carried on for the last six months.
The instruction is given both in classes at stated meetings
and to individual mothers in their own homes.
Obstetrical service is not provided, but the mothers are re-
ferred to the family physician or to the excellent obstetrical
service of the university. Practically all of the mothers who
have had prenatal instructions have found it possible to nurse
their own babies. The postnatal instruction is given to the
mothers at the Welfare Stations, in the homes, by the visiting
nurses, and at the monthly mothers' meetings. The instruc-
tion consists of lectures and demonstration. The consulta-
tations are held bi-weekly in the different stations, and the
days so arranged that a consultation is conducted every day
of the week in some part of the city.
All ill babies are referred, to the family physician, hospitals
or the University of free dispensary. Milk is distributed only
if the family is very needy, or if the mother is unable to un-
derstand and to carry out the home modification
XI. The work is financed entirely by private subscription and by
membership fees in the organization. The organization has
been the beneficiary of one large donation in the past year.
Much of the larger program carried on this year was made
possible through this donation.
F. W. SCHLUTZ, Medical Director.
MISSOURI
INFANT FEEDING CONFERENCE OF THE ST. 1.OUIS PURE
COMMISSION
May 1st -October 1, 1913
I. The registration of births does not serve as a starting point
for our work
II. In the neighborhood of 4 or 5 per cent of the infant population
has been reached by the work of our commission.
III. Our work is carried on throughout the entire year
IV. Our work was started in the spring of 1903; we were incor-
porated on February 26, 1904, and the first work began June
June 28, 1904. The infant mortality has declined almost every
year for the past twenty years or more. It is very difficult
to state exactly what effect the work of the Pure Milk Com-
mission has had upon the reduction of infant mortality in
396 EEPOETS
St. Louis for the reason that the decline in mortality set in
many years before this work was under way. However, the
decline has been very noticeable these past six or seven
years.
V. We have no connection with the Department of Health.
VI. We include both prentaal and postnatal work in our activities.
VII, We cooperate with the Children's Aid , Visiting Nurse Association
and Washington University obstetric work.
VIII. Our prenatal work is done by nurses who give instructions to
mothers in their own homes. This work has been done for
three or four years, and its effect on the health of both
mother and child has been very encouraging. We do not pro-
vide obstetrical service,
IX. For our postnatal work we have eight welfare stations where con-
ferences are held weekly and bi-weekly. Four of these are
on the north side and four on the south side. Last year, from
May 1st to October 1st, we had a total of 271 conference days,
with an enrollment of 612 babies; the total individual consul-
tations between physicians and mothers numbered 2,523.
Seven of these welfare stations continue through the winter.
Besides the work done at the station, nurses visit the mothers
in their homes, giving instruction on every point. Milk is
both distributed and sold.
X. We have ten doctors on our staff. The nurses are furnished by
the Visiting Nurse Association.
XI. The work is financed by public subscription.
A. S. BLEYEB, Chairman, Clinics Committee,
ST. LOUIS CHILDREN'S HOSPITAL
I. The registration of births does not serve as the starting paint
for our work.
II. Our hospital reaches in the neighborhood of two per cent of
the infant population.
III. The work of the St. Louis Children's Hospital is carried on
during the entire year.
IV. Our work was first started on April 1st, 1910.
V. We have no connection with the Department of Health.
VI, We cooperate with the Social Service Department, the Visiting
Nurse Asociation and the Pure Milk Commission.
VII. The Social Service Department, with whom we cooperate, does
prenatal work.
VIII. (a) Instructions are given in personal and home hygiene; diet;
regulation of work, exercise; clothing; care of breasts;
preparation for home confinement; recognition of patho-
logical symptoms.
(b) The instructions are given by the "prenatal" nurse indi-
vidually in the hospital dispensary and in the home.
(c) This prenatal work has been carried on since May 1, 1912,
to October 1, 1913.
(d) We have reached 835 mothers.
AFFILIATED SOCIETIES 397
(e) We have proved a decrease of 26.4 per cent in infant mor-
tality within the first month of life. Only had two cases
of eclampsia, although many had pre-eclamptic symptoms
when first registered. Where there were abortions previ-
ously in the instructed group, we had one-seventh as
many.
IX. For our postnatal work we have our own infant feeding clinic,
where instruction is given by the physician, and there are bi-
weekly conferences between the doctor, the nurse and the
mother. The nurses also give instructions in the home on
feeding, care of sick babies, etc. We both sell and distribute
milk.
X. We have one doctor on our staff, and we have the assistance of
the Social Service Department, the Visiting Nurse Association
and the Pure Milk Commission Clinics are held twice weekly.
XI. The infant work of the hospital is supported by voluntary con-
tributions.
MBS. R. McK. JONES, President.
NEW HAMPSHIRE
INFANT AID ASSOCIATION
Manchester
I. The registration of births does not influence our work in any
way.
II. This Association reaches about one-tenth of the infant popula-
tion of Manchester.
III. Our work is only carried on during July and August.
IV. Our work was started July 1, 1912, since which time there has
been a marked decrease in infant morbidity and mortality,
but we have no statistics.
V. We have no connection with the Department of Health except
inspection of the milk supply.
VI. Our work is entirely independent, having no relation to any
other welfare work done in Manchester.
VII. Our Association does no prenatal work.
IX. We have one welfare station, holding the usual weekly confer-
ences; our nurses also go into the homes and give daily in-
struction to the mothers on the care of the baby, as well
as giving nursing care to sick babies. We distribute milk
to those who are too poor to buy it, and sell it to such as
can afford to pay.
There are three doctors and nurses on our staff.
XI. We are entirely dependent upon private donations for the finan-
cing of our work.
REMSEN VABJOK, Secretary.
NEW JERSEY
THE VISITING NURSE ASSOCIATION
Elizabeth
A prenatal clinic was opened in August at the Elizabeth General
Hospital and attended by one of our nurses five days each week; a
babies' clinic at the same hospital is also attended by a visiting nurse,
but the records of the clinic are in the possession of the hospital.
398 REPORTS
Three nurses are employed by the Association.
Obstetrical cases are not attended at confinement, but are given after
care.
The Association has only unofficial cooperation with the Board of
Health and has nothing to do with the registration of births.
During the year the nursing staff has been entirely reorganized and
a new system of records instituted so that next year it will be pos-
sible to compile a statistical report.
COKDELIA MRAVLAG, Secretary.
THE BABIES' HOSPITAL. OF NEWARK
Organized and incorporated May, 1896.
The management is non-sectarian, consisting of a Board of Direc-
tors, who hold the property and administer the permanent funds ; a
Board of Managers, who collect and disburse the funds for current
expenses, and supervise the household and training school; and a
Medical Board, who control the medical and surgical work.
This hospital was designed:
1. To provide care and treatment for sick infants of the poor under
three years, not suffering from any contagious disease.
2. To establish a school for the training of intelligent young women
to care for the children of the better classes.
3. To furnish suitable food for the infants of indigent mothers, who
have proved to be unable to nurse their little ones, and who
can not properly prepare the milk at home, which is provided
at cost to those who can pay, or free to the destitute.
4. To provide a place where physicians may study the diseases of
infancy and childhood.
The capacity of the hospital is 35 cribs.
The extension work embraces three clinics a week at the hospital,
and four consultation stations, located in settlement house, playground
and public school, where infants are weighed and the mothers encour-
aged to nurse them if possible, and general instruction given by the
doctor in charge as to management and care. A graduate nurse,
speaking four languages, is in attendance at these consultations ; she
subsequently follows to their homes those in need of more definite
directions, as well as those taking milk from the dispensary. She
visits also all patients discharged from the hospital.
The support of the hospital is derived from subscriptions from direc-
tors and managers, voluntary contributions and a small city appropria-
tion.
A new building is greatly needed, as the present one is entirely in-
adequate for the work, and it is hoped one will soon be in course of
construction.
HENEY L. COIT, Medical Director.
CLARA E. WATKINS, Superintendent.
THE BABIES' HOSPITAL MILK DISPENSARY (NEWARK)
I. The registration of births does not serve as the starting point
for our work.
II. Ten per cent of the infant population is reached by the work
of our Association.
AFFILIATED SOCIETIES 399
III. Our work is carried on during the entire year.
IV. Our work started in 1896.
Replying to inquiry regarding the effect it has had on infant
morbidity or mortality: The mortality of cases treated in
the hospital is probably reduced 60 per cent. In the social
service work of the hospital, the viability records made by
our scoring system show very accurately the effect of educa-
tion and good milk. One hundred cases which were visited
regularly by the nurse during the year showed that the aver-
age living prospect of these infants was only 16 per cent per-
fect and at the end of the year the average had been raised
to 74 per cent, which represented an improvement of 58 per
cent, or an advance of three-fifths toward a perfect normal
condition.
V. We have no connection with the Department of Health.
VI There is general cooperation between our work and that of
other welfare activities.
VII Our activities have been limited to postnatal work
VIII. We have seven consultations for mothers with infants, and
three medical clinics.
IX. The instruction is given orally by physicians; and includes
visits by nurse, distribution of educational pamphlets. Our
work comprises weekly conferences between doctor, mother
and nurse, instruction of mothers in their homes, nursing
care of sick babies. It also includes the distribution or sale
of milk.
X. Our staff consists of twelve physicians, three trained nurses,
one post-graduate nurse, sixteen nursery maids.
XI. Our work is financed by voluntary contributions and a city ap-
propriation to support ten beds in the hospital.
HENBY L. COIT, Medical Director.
O. E. WATKINS, Superintendent.
THE DIET KITCHEN OF THE ORANGES
Orange
The Diet Kitchen of the Oranges was organized April 13th, 1895.
We have two supply stations. At the main kitchen are held the
consultation class for mothers and the "little mother's class" for
teaching little girls the essentials of personal and infant hygiene;
here also milk is modified for the babies, and milk and eggs are dis-
tributed to the sick poor daily,
At the Valley branch milk and eggs are also distributed daily.
Charges for the supplies are determined by the ability of patients to
pay. We have two doctors and two nurses on our staff.
The League has divided the work in the Oranges into seven districts,
two of which have been assigned to us.
A physician is in attendance one day a week at the consultation
classes held at our two welfare stations.
Since last June our nurse has spent her entire time in the homes
giving instruction to the mothers in every branch of infant hygiene.
The results have been most gratifying, a large percentage of the mothers
400 REPORTS
now preparing the milk for their babies.
Out of 192 babies attending the consultation classes during the past
year there were only four deaths.
Births occurring in our districts are reported to our nurse, she visits
these homes at once and invites the mothers to the consultation classes.
We feel if the babies are started right much illness may be pre-
vented.
Our Association has no department for prenatal work, but in many
cases the nurse has given advice and instruction to prospective mothers.
Our work is supported by voluntary contributions.
ANNA T. STEWART, Secretary,
NEW YORK
NEW YORK ASSOCIATION FOR THE BLIND
Report of
Tue Committee for tne Prevention of Blindness on its Work for
Infant "Welfare
SEPTEMBEB 30, 1912, TO SEPTEMBER 30, 1913
Purpose, Scope and General Results of Worlc. The object of the
Committee for the Prevention of Blindness is "to ascertain the direct
causes of preventable blindness and to take such measures in coopera-
tion with the medical profession as may lead to the elimination of
such causes." The field of its activities is limited nominally to New
York State, but the committee has always responded to requests for
assistance from workers from other States and will continue to do so
until a national organization exists to which such work can be referred.
The work of the committee during the year ending September 30,
1913, has, like that of the preceding years, consisted of investigation
into the preventable causes of blindness and impaired vision; coopera-
tion with various agencies and individuals in practical measures for
the prevention of blindness; the support of such legislation as was be-
lieved would further this work; and the education of the public at
large concerning these causes by means of the publication and distribu-
tion of literature, public speaking, photographic exhibits, lantern slides,
magazine articles and the press.
The subjects considered by the committee have included ophthalmia
neonatorum, midwifery reform, trachoma, lighting, industrial accidents
and wood alcohol. A report upon the committee's work in connection
with ophthalmia neonatorum and midwifery reform is herewith ap-
pended.
OPHTHALMIA NEONATORUM
Investigation. Figures recently collected by the committee from
schools for the blind throughout the country show that out of a total
of 2,327 pupils in 21 schools, 684, or 29.2 per cent of the pupils are need-
lessly blind from ophthalmia neonatorum; 88 of the 386 children ad-
mitted for the first time during the last school year are blind from
ophthalmia neonatorum, thus showing that the percentage of needless
blindness from this cause in schools for the blind continues about the
same this year as for preceding years:
AFFILIATED SOCIETIES 401
191288 out of 386 new admissions 22.7% blind from O. N.
191188 out of 415 new admissions 21.2% blind from O. N.
191084 out of 351 new admissions 23.9% blind from O. N.
It was found upon investigation of 108 cases of ophthalmia neonatorum
reported from the various eye clinics in New York City to this com-
mittee that 62 were attended by physicians, 43 by midwives and three
were emergency cases attended by neighbors. In 14 of the 62 cases at-
tended by physicians a prophylactic against opthalmia neonatorum was
used at birth, and by 11 of the 43 midwives. Of eleven cases in which
injury resulted, six lost one eye, two eyes were scarred, while three
infants became totally blind. The cases of total blindness all occurred
in the practice of physicians, while of the remaining nine, seven were
physicians' cases and two were midwives'.
Legislation. The committee has supported the State Commissioner
of Health in his successful application for a renewal of the grant in
the Supply Bill of 1913, to make possible the free distribution of
prophylactic outfits for the prevention of blindness from ophthalmia
neonatorum. This appropriation which was diminished $2,500 in the
previous year was increased to $5,000 in 1913.
Subsequent to a request made by this committee to the effect that
all midwives be required to report redness and swelling of the eye-
lids with discharge from the eyes of new-born infants in their care, the
New York City Department of Health amended its rules and regula-
tions (June 3, 1913,) governing the practice of midwives to include
the following regulation :
"22A. "When a child delivered has or develops sore eyes, or
any redness or discharge from the eyes, the midwife in at-
tendance must at once report to the Department of Health the
name and address of the mother and state the time when such
condition of the eyes was first noticed."
The committee has assisted in the preparation of a model law for
the prevention of blindness from ophthalmia neonatorum which was
drafted by the Committee on Prevention of Blindness of the American
Medical Association, for possible adoption in the various States of this
country.
Data and information in regard to existing laws affecting the con-
trol of ophthalmia neonatorum in this and other States have been
given to workers in Oklahoma, Kansas, Idaho, Oregon, Iowa and New
Jersey. This assistance was sought preparatory to legislation in the
States mentioned. This legislation was contemplated as a result of
interests aroused by the statistical reports showing the prevalence of
blindness from ophthalmia neonatorum throughout the country, which
this committee issues each year and sends to superintendents of schools
for the blind and to other workers.
MID WIVES
Investigation. The committee has collected from State and City
Boards of Health throughout the country reports upon the propor-
tion of births which are now being attended by midwives. An estimate
based upon these reports indicates that midwives attend about 40 per
cent of all births.
The committee has made a study of State and country laws and city
ordinances which are related in any way to the training, registration
and control of midwives practising in this country. The following sum-
402 REPOETS
mary indicates the inadequacy of existing legal provisions, while cor-
respondence with public officials having jurisdiction over this group of
practitioners discloses deplorable ignorance on their part of the status
and extent of this profession.
It was found that midwives are allowed by law to practice un-
restricted in twelve States,* while there are no laws relating to their
training, registration or practice in fifteen States.! In the remaining
twenty-two States, where there are such laws, fifteen? require examin-
ation in addition to licensure. In no one of the seven States in which
it is required that midwives shall be trained before examination and
licensure are there recognized midwife training schools. The only
training school for midwives under reputable auspices of which the
committee is aware is the one connected with Bellevue Hospital, estab-
lished in 1911 as a result of the efforts of the committee.
During the year, the committee's executive secretary has registered
as a midwife with the New York City Department of Health, as have
also several other members of the nursing profession. This was done
as the initial step toward raising the status of the profession of mid-
wifery through the enrollment of a superior class of women among its
members.
At the first annual meeting of the American Association for Public
Health Nursing, with Miss Lillian D. Wald as President, held at At-
lantic City in June of this year, a section on Infant Welfare was
created for the purpose of considering the subjects of the care and
feeding of infants, prevention of blindness and midwifery. The execu-
tive secretary was appointed chairman of this section, with power to
select sub-chairmen to deal with the respective subjects. It is be-
lieved that this action on the part of such an important nursing body
will be productive of valuable results in the work for midwifery re-
form and the prevention of blindness.
The interest in midwifery reform in this country was evinced by
the American Public Health Association made up of health officers and
sanitarians from the United States, Canada, Mexico and Cuba. The
executive secretary was invited to present a paper on the midwife
problem at the annual meeting of this association held in Colorado
Springs in September. As she was unfortunately unable to attend the
conference her paper will be published in an early issue of the journal
of ihe association.
During the past session of the Legislature the committee watched
the progress of a bill "To amend the public health law, in relation
to the practice of midwifery." Since the provisions contained in this
bill were inadequate the committee was gratified that it did not be-
come a law. It is the purpose of the committee to support or inaug-
urate during the next session of the Legislature, legislation necessary
to secure the training, examination, licensure and control of midwives
by State authority.
CAEOLYN C. VAN RLAECOM, Executive Secretary.
*Alabama, Arizona, Arkansas, Florida, Georgia, Idaho, Kentucky, Maine,
South Carolina, Tennessee, Virginia, West Virginia.
{California, Delaware, Massachusetts, Michigan, Mississippi, Nebraska, New-
Hampshire, New Mexico, New York, North Dakota, Oklahoma, Oregon, Rhode
Island, South Dakota, Vermont.
t Connecticut, District of Columbia, Illinois, Indiana Louisiana, Maryland,
Minnesota, Missouri, New Jersey, Ohio, Pennsylvania, Texas, Utah, Wisconsin,
Wyoming.
Illinois, Maryland, Missouri, New Jersey, Ohio, Pennsylvania, Wisconsin.
AFFILIATED SOCIETIES 403
THE NEW YORK CITY DIET KITCHEN ASSOCIATION
OCTOBER, 1912, TO OCTOBER, 1913
During the year the New York Diet Kitchen Association has con-
ducted the work of its milk stations along the usual lines, and in addi-
tion has increased its staff of nurses maintained for educational and
welfare work, and extended its efforts in prenatal work till all sta-
tions, except one, are now registering expectant mothers.
The one exception made at the request of the New York Milk Com-
mittee was of a station situated in a district where nurses of the
Milk Committee were engaged in this line of work, and it was desired
to retain the territory so covered for purposes of demonstration.
January 1st, 1913, one station was closed in a district where recently
established municipal stations hi the same region could cover the work,
and both in the interests of cooperation and to prevent duplication of
effort, it was decided to withdraw the Diet Kitchen station.
This action leaves eight stations that the Association is still support-
ing.
Originally established in 1873 to supply nourishing food to patients
sick in their homes, the Association early took part in the crusade
for pure milk, and for many years has made a feature of securing
that for the babies attached to the stations, and since 1908 has been
increasing the amount of its instructional work, so that for some years
active work among the babies and mothers has been the most important
part of its activities.
The Association is an affiliated member of the Babies' Welfare As-
sociation, and cooperates with the Department of Health and the
baby and general welfare agencies of the city.
Each of the eight stations has a well defined district, arranged by
the Milk Station Committee of the Babies' Welfare Association, and
this district forms the basis for the work, new cases being secured by
canvass and through cooperating agencies.
As notices of birth registration from the districts cannot be regu-
larly supplied from the Department of Health, birth registration does
not serve as a starting for the work.
During the past year 4,358 babies were under the care of the As-
sociation stations, and there were only 42 deaths, or less than 1 per
cent from all causes, and of this number ten were due to digestive
diseases.
The prenatal work, first definitely organized in one station in Sep-
tember, 1912, was taken up by four more stations in January, 1913, and
in August two others began the systematic registration and instruction
of expectant mothers, so that at the time of reporting all the stations
with the exception of the one excepted for the reason previously given
are regularly engaged in the prenatal work.
The Association does not provide obstetrical services, but as soon
as a case is registered in a station, the station nurse puts the mother
under the care of a doctor, maternity hospital or clinic giving services
in the home, and cooperates with that institution or physician in carry-
ing out instructions to the patients. At this time the Association nurses
are receiving excellent cooperation from seven institutions and clinics,
and physicians as well.
The nurse instructs the mothers in groups or singly at the stations
in regard to proper care during pregnancy and visits in the homes lor
further instruction and supervision of health.
404: REPORTS
Up to date there have been 295 mothers registered at the stations,
and of this number 116 have already been delivered. No deaths among
the mothers; one abortion, history showed five previous abortions;
two miscarriages from accidents; three babies died; one, congenital
heart disease; one, taken from the hospital top soon against the doc-
tor's wishes ; one, cause not ascertainable. While the general improve-
ment in both mothers and babies has been very perceptible after pre-
natal care, the Association has not been engaged in the work long
enough, perhaps, to offer figures of much statistical value, but in one
direction the gain has been marked and deserves attention. Of the
113 babies, 99 were breastfed, and with the exception of the three
who died, all these have been breastfed for periods ranging from three
to nine months. Postnatal care included weekly conferences at the
eight stations with doctors and nurses, instruction at station outside
of conference hours by nurses, home instruction and nursing care of
sick babies in emergencies, otherwise only until the babies can be
otherwise provided for.
Milk is sold, or in some instances given away, at all stations.
Staff of physicians : 6 assigned by the Department of Health ; 7 vol-
unteer doctors. Nurses: 5, supported by the Association; 3 assigned
by the Department of Health for weekly conferences during the winter,
for all day during July and August.
The work is financially supported almost entirely by contributions
and subscriptions, the city only appropriating $500.00 yearly towards
expenses.
MAEIA L. DANIELS, Superintendent.
HEBREW INFANT ASYLUM
New York City
The Hebrew Infant Asylum admits children from the time of birth
up to the age of four years, accepting those who are not able to be
cared for at home. At present, it has about 375 children, of which
there are about 90 under one year of age and the same number be-
tween one and two years. In 1912 we lost 12 children, 5 under one
year of age. The infants and children who either have no parents, or
on account of poverty, or other causes, are unable to be cared for by
their parents, are committed by the Charities Department to our institu-
tion for a period of months or years. In this way many of the infants
are saved.
Connected with this institution there is a training school for nursery
maids. The wards for the infants and smaller children are in charge
of trained nurses. From time to time throughout the year, a wet nurse
is employed.
The plant consists of a main building, with wards, play room, diet
kitchen, infirmary, etc., a reception building for older children, com-
prising four floors which are completely isolated, and a new recep-
tion pavilion for infants, containing 12 cubicles modeled after those
of the Pasteur Institute. All milk is thoroughly pasteurized.
ALFRED F. HESS, Attending Physician.
AFFILIATED SOCIETIES 405
INDUSTRIAL, DEPARTMENT METROPOLITAN LIFE INSURANCE
COMPANY
New York City
Through our nursing service in the year 1912, we gave visiting nurse
service to 131,092 polieyholders. Our statistics for the entire year
have not been completed, For the first six months of 1912 we gave
nursing service to 6,374 maternity cases. To these, a total of 50,794
visits were made, or an average of 12 visits per patient.
The maternity service until now has been somewhat experimental.
In a number of cities we gave maternity service to all policyholders
who desired it, the service being given to normal cases as well as to
cases where complications arose. In other cities, the service was given
only where there were complications. As a result of our experience,
we have decided, beginning December 1st, to extend the service to in-
clude all normal maternity cases. This service, I may say, covers as a
rule prenatal visits and such service as can be given by a visiting
nurse.
The nursing service which we are giving is supplemented by the
literature which we distribute, particularly our pamphlet, "The Child."
The value of this pamphlet has been demonstrated in various ways.
Recently a delegation, representing the New York Midwives' Associa-
tion, requested that we change the wording in this pamphlet, in which
the suggestion is made to our policyholders that if they expect mater-
nity, they should have a physician or go to the hospital, instead of
using a midwife. The committee claimed that as a result of the distri-
bution of this pamphlet policyholders were no longer willing to accept
the services of midwives.
Other instances have been brought to our notice in which mothers
as a result of reading the pamphlet and realizing that improper service
was being given to their infants, particularly as to the care of the eyes,
have discharged midwives and engaged physicians.
LEE K. FBANKEL, Si$tTi Vice-President.
NEW YORK MILK COMMITTEE
I. Our cases are referred to us by other agencies, and we do not
search them out from birth registration. "We do, however,
use the birth record as a means of checking up the efficiency
of our work.
II, As our work is mainly educational and for the benefit of all
classes of population, I would say that we reach the entire
infant population. Our direct work is purely for the purpose
of demonstration and deals with only a limited portion of the
infant population.
III. Our work is carried on during the entire year.
IV. Our work was started in 1907.
Effect upon infant morbidity or mortality : Since the
establishment of the infant milk stations in this city under
our direction the infant mortality of the city has been lowered
from 125.6 per one thousand births in 1910 to 105.3 in 1912.
If the decrease maintained so far this year is held for the
406 REPORTS
remaining two months the rate for this year will be about
100. Among the mothers handled by our prenatal corps In
the experiment just finished, we have reduced the deaths for
infants under one month of age 29.9 per cent as compared
with the rate for the Greater City, and the stillbirth rate
among tho&e mothers has been reduced 17 per cent.
V. Connection with the Department of Health : Our committee has
an arrangement with the Department of Health whereby we
cooperate with them in the work of conducting infant milk
stations, by inspecting the stations from time to time and mak-
ing suggestions as to their management. We also turn over
to the Department of Health results obtained from our work,
and the Department has adopted our methods in establishing
and conducting milk stations, and in carrying on prenatal
work.
VI. Relation to other welfare work: The Milk Committee was one
of the promoters of the Babies' Welfare Association, which is
a federation of all the agencies in this city interested in infant
welfare work, including the Department of Health, Through
this federation we cooperate with all the other agencies in
the field, thereby avoiding duplication of effort.
VII. The activities of our Association include prenatal as well as
postnatal work.
VIII. Plan followed in prenatal work:
Character of instruction: The mothers are placed under
the influence of our prenatal nurses as early in pregnancy as
possible. They are given instruction in practical hygiene and
in the care of infants. They are taught how to keep their
homes in a sanitary condition, and how to prepare for the
birth of their baby.
The instruction is given by a visiting nurse in the home
to the individual mother. This nurse makes periodical visits
and calls on the committee's physician when necessary in
emergency cases.
This work has been carried on since August 1, 1911.
There have been 2,153 different mothers enrolled in that
time.
We do not provide direct obstetrical service. We cooperate
with other agencies. However, in referring our cases to
them for obstetrical care we watch these cases to see that
proper care is given.
Detailed figures of our work are as follows:
NEW TOEK MILK COMMITTEE
STATISTICAL STATEMENT OF PRENATAL WORK FOB PERIOD
AUGUST 1, 1911, TO SEPTEMBER 1, 1913
Total number of cases 2,153
Total number of mothers supervised 2,150
Total number of mothers died &
Total number of living births 2,102
Total number of stillbirths 86
Total number of babies born 2,188
Stillbirth rate per 1,000 living and stillbirths 30.3
Total number of deaths under 1 month 60
AFFILIATED SOCIETIES 407
Death rate under 1 month per 1,000 living births 28.5
Babies entirely breastfed 1,901 93.09%
Babies mixed fed 78 3.81%
Babies artifically fed 63 3.08%
(Number of pairs of twins 34)
(Number of sets of triplets 1)
New York Milk Committee death rate under 1 month. . 27.4
New York City death rate under 1 month 38.2
Percentage reduction 29.9
If the Milk Committee's rate had prevailed throughout the
entire city during 1913, to date, it would have meant a saving
of 1,045 infant lives.
New York Milk Committee stillbirth rate per 1,000
births (living and still) 39.3
New York City birth rate per 1,000 births (living and
still) 47.6
Percentage reduction 17.0
As the New York Milk Committee is positive as to the num-
ber of stillbirths which have occurred in their work, the
comparison of its rate with that of the reported stillbirths of
New York is hardly fair, as it is estimated that fully 50
per cent of the stillbirths which occur in New York are not
reported.
Estimating on the basis that 50 per cent of the stillbirths
are not reported, if the stillbirth rate of the committee had
prevailed throughout New York City during 1912 there would
have been a saving of 1097 lives. Adding to this the number
of preventable deaths under 1 month, the extension of the
milk station work would have meant a saving of 2,142 lives.
Prenatal work is an extension of Milk Station work.
IX. Plan followed in postnatal work:
Our direct postnatal work at present is confined to a con-
tinuation of our prenatal cases until the end of the first
month of the baby's life, during which time we instruct and
direct the mother in her home in the care of the baby. We
have running nine stations for this work. -At none of these
stations have we distributed milk, as we turned our milk sta-
tions over to the Board of Health on the completion of our
demonstration with them in 1911. We are now running one
of our stations as a general health centre, where we deal with
all the family problems.
Weekly conferences are held at the station by the doctor,
mother and nurse. Instruction is given to mothers in their
homes, and nursing care is given in emergency cases.
X. Staff :
We have one paid doctor, and nine paid nurses on our
staff. We have in addition to these a volunteer doctor and
two advisory physicians.
XI. Our work is financed by voluntary contributions.
In addition to the above work we do a great deal of indirect work by
conducting a series of lectures around the city on the milk supply and
care of the babies. We also issue a great deal of literature for the
use of mothers, and contribute a large part of the expenses of conduct-
ing the Babies' Welfare Association's Clearing-House.
GABEET SMITH, Secretary.
408 REPORTS
HEALTH BUREAU
Rochester, N. Y.
I. The registration of births is used as a basis for the baby-saving
work of the Bureau.
II. About 20 per cent of the approximately 6,000 infant population
is reached by the work of the visiting nurses of the Child
Welfare Stations during July and August only.
III. and IV. This work was started in 1S97.
The work is now and always has been carried on by the
Bureau of Health.
VII., VIII. and IX. Up to the present time there has been very little
prenatal work.
We have 10 Child Welfare Stations. There are two nurses
in each of three stations and one nurse in each of the other
seven stations.
We confine our instruction almost wholly to the home, be-
cause we believe that the work of the nurse is to teach, the
mother in the home.
We have no weekly conferences.
Milk, with an average count of under 20,000 per c. c., is
sold at cost.
XI. Our work is financed by the Bureau of Health.
Last season our nurses visited 934 families, in which there were
2,547 children under 14 years of age and 174 over 14. Of the 952 babies
visited, 71 were taken to the Infants' Summer Hospital and 49 to
other hospitals and dispensaries. There were 21 deaths.
GEOKGE W. GOLEE, M. D., Health Officer.
THE INFANT WEOLFARE COMMITTEE OF THE ASSOCIATED
CHARITIES AND CHURCHES OF SYRACUSE
Early in June, 1913, the president and secretary of the Associated
Charities appointed a committee to organize an Infant Welfare Asso-
ciation in Syracuse, which should establish infant welfare stations and
conduct the work of education and instruction in saving the lives of
babies. The committee met for the first time on June 19th. It was
made up of Miss Mary Jenkins, Mrs. Dana C. Hyde, Mrs. Albert F.
Fowler, Mrs. Joseph C. Palmer, secretary and treasurer; Mr. Arthur
Costello, and Dr. Joseph C. Palmer, president, who composed the active
members of the Association. As associate members were enroll-ed many
individuals and organizations who generously contributed to the carry-
ing on of the work. These numbered about one hundred and eighty, and
among them were included The Syracuse Bureau of Health, which
donated the services of five school nurses Miss Anna Scott, Miss
Bertha McChesney, Miss Leilia Lennox, Miss Louise Cramp and Mrs.
Catherine Quinby who worked faithfully and zealously through the
hot summer months, and to whom much of the credit of the first season's
achievements is due. The Syracuse Herald, which, after itself making
a generous contribution, was untiring in its efforts in raising funds and
so broadening and enlarging the scope of the work; the Board of
Education, which gave the use of rooms in the two schools, where
stations were established; the officers and directors of the National
Bank of Syracuse; the Solvay Guild; the Open Air School Aid Soci-
AFFILIATED SOCIETIES 409
ety; the Young Men's Hebrew Association of Syracuse; the Syracuse
Brewers* Exchange; the People's Ice Co.; the E. I. Bice Ice Co.; a
number of church societies and clubs.
Especial mention should be made of the physicians comprising the
medical staff, who gave freely of their time and efforts. They were
most faithful in their regular attendance and by conducting the physi-
cal examinations, by directing weighings and by prescribing feedings,
contributed largely to the success of the undertaking. Among these
were. Dr. Philip Potter, Dr. Lamed, Dr. Domser, Dr. Meller, Dr.
Blum, Dr. Wright and Dr. Geiger, alternate.
The thanks of the committee are also due to Dr. Wynkoop and
Dr. Foreman, who very kindly consented to direct the work in August
during the absence of the president, and to Dr. Mercer and Dr. John-
son, who acted as consultants.
The first welfare station was opened on June 24th at the Emma
Willard School, near the corner of Grape and East Adams Streets,
which is said to be the centre of the Jewish population of Syracuse,
which in 1910 was somewhat over eight thousand. A second station
was opened at the Townsend School, at the corner of Townsend and
Ash Streets, which is near the heart of both the German and Italian
colonies, the former numbering about thirty-eight thousand, and the
latter about sixteen thousand. Both stations were closed on September
first The detailed report follows:
Total amount certified milk dispensed 4,847 quarts
Total amount inspected milk dispensed 7,593 "
Total amount milk dispensed 12,440 "
Total amount ice used 19,135 Ibs.
Total number of visits by the nurses to the homes 841
Total number of welfare station days 123
Total number of homes scored 94
Highest percentage given on any score 100 per cent
Lowest percentage given on any score 26 "
Average 68.1 "
Greatest improvement shown on re-scoring form 56 to 81 "
Town-
Adams send Total
Number of cases registered 230 243 473
Babies breastfed 36 31 67
Babies bottlefed 101 154 255
Babies on mixed feeding 28 13 41
Expectant mothers without babies 3 8 11
Cases registered, no milk supplied 48 36 84
Applications refused 14 1 15
Number dropped from roll 41 73 114
Regular attendants 115 48 163
Very regular attendants 12 80 92
Number of cases sent to hospital 8 8
Number of cases sent to Visiting Nurse Camp. .303
Number of cases sent to Syracuse Free Dis-
pensary 3 3
Number of cases died. 2 1 3
Total number expectant mothers 6 9 15
Mothers attended at birth by midwives 4 35 39
Babies under six months of age 78 69 147
Babies from 6 to 12 months of age 65 68 133
410 REPORTS
Town-
Adams send Total
Babies from 12 to 18 months of age 58 50 108
Babies from 18 to 24 months of age 24 30 54
Babies over 2 years 5 22 27
Average age 9 mos 9 mos 9 mos
Number of boys 132 110 242
Number of girls 101 109 21Q
Number of patients receiving milk gratis 21 107 128
Number of patients receiving milk with partial
payment 172 75 247
Number of patients receiving milk with full
payment 5 2 7
Average amount paid for milk per quart .02%
Number of Jews ISO 5 185
Number of Italians 7 199 206
Number of Germans 20 20
Number of Negroes 13 13
Number of Americans 20 29 49
TKEASUBER'S REPOET
Receipts Disbursements
Contributions $1,897.78 Printing $37.75
Rebate on milk 345.73 Supplies 31.00
Sale of milk 307.20 Milk 1,286.09
Cleaning 42.75
Total $2,550.71 Cartage 5.25
Disbursements 1,464.58 Screens 6.00
Photographs , 9.50
Balance on hand $1,086.13 Stationery 3.67
Signs 22.65
National Society fee. . . 5.00
Home-made ice boxes. . 2.80
Incl 12.12
$1,464.58
JOSEPH C. PALMER, M. D., President.
THE BABY WELFARE COMMITTEE!
ITtica
The committee of eight members which conducted the Utica Babies'
Pure Milk and Health Station was reorganized in the spring of 1913
under the name of The Baby Welfare Committee of Utica, and its
membership increased to fourteen. A campaign for funds was begun
in May, through private subscriptions, and at the end of June this
was supplemented by placing four dozen quart milk bottles in the
drug and dry goods stores bearing placards headed "Do It For The
Baby" and asking people to put their spare pennies in the bottles.
From the subscriptions the committee obtained $645,73; from the
milk bottles, $226.90, and this with a balance in the bank of $66.01
gave a working fund of $938.64.
AFFILIATED SOCIETIES
The committee opened two milk stations on July 1st, the method
employed the year before of using the domestic science rooms being
again adopted. The staff consisted of a medical director, two physicians
in charge, three attending physicians and two visiting nurses. The
stations closed on September first. In the two stations there was a
total enrollment of 382. There were enrolled at the clinic 250. Two
Hundred and seventy patients were supplied with 5,335 quarts of
milk and the nurses made 1,608 visits to the homes. There were in
all nine deaths, most of them among babies brought when moribund
or attending but once. The physicians of the city took greater interest
in the stations than the year previously, 29 physicians referring 118
babies to the station for the milk. The milk used was from a model
dairy and was practically equivalent to a certified milk, and owing to
the special rates at which the committee sold the milk it was possible
to dispense it at the rate of six cents a quart. The milk was sold in
pint and quart bottles, the nurses instructing the mother in the modi-
fication at the homes.
The total expense of running the two stations for the two months
of the summer was $462.44, thus leaving the committee at the end of
the season with a balance of $476.20. It will thus be seen that the
committee expended less than half of the money donated for the pur-
pose of conducting the summer stations.
It was then voted to continue the stations, or at least one through-
out the winter. Much difficulty was experienced in obtaining proper
quarters, but by the middle of October the Utica Park Board offered
the use at whatever hours required of a new public bath house in the
Italian quarter, the dressing rooms of which are ideally arranged for
a milk station and clinic. The winter station was opened on October
15, the nurse being in attendance daily from eight to ten to dispense
the milk, and the physician holding clinic two afternoons a week. The
expense of this is something below one hundred dollars a month.
Immediately on opening the winter station the nurse took up pre-
natal work in a small way. The winter station, though not so largely
patronized as the summer stations were, has proven decidedly successful,
and the prenatal work is spreading rapidly.
In the matter of educational work, the nurse takes every oppor-
tunity available to educate not only the mothers on her lists, but the
neighbors as well. The members of the medical staff have delivered lec-
tures in schools, factories and to the Camp Fire Girls on baby wel-
fare, and it is hoped that within a few weeks a number of Little
Mothers' Leagues will be organized.
The Board of Health statistics for the year, though not showing any
reduction in the infant mortality for the year, show a decidedly low-
ered infant death rate during the months when the stations were open,
the high rate for the year being due to an exceptionally heavy infant
mortality during the first four months of the year, before the com-
mittee had undertaken its work. The summer infant mortality for
1913 was 22 per cent lower than for 1912.
T t WOOD CLARKE, Medical Director.
NORTH OABOLINA
STATE BOARD OF HEALTH
The work that our Board is doing along the lines of preventing
infant mortality is a part of the general educational work of this
412 REPORTS
Board. We issue pamphlets and leaflets, and also have had a great
deal to say in our regular press service on the subject of infant mor-
tality.
I recognize the importance of the work of the Association for Study
and Prevention of Infant Mortality, and that, with the single excep-
tion of tuberculosis, it is dealing with the greatest factor in the high
death rates of our country.
W. S. RANKIN, M D., Secretary.
OHIO
THE BABIES' DISPENSARY AND HOSPITAL
Cleveland
I. All birth registrations are submitted to us and all cases within
the area of our work are investigated by the nurses.
II. We reach about one-fourth of the registered babies under one
year of age.
III. Our work is carried on throughout the entire year.
IV, Our work was started July, 1906. Both infant morbidity and
mortality has been lowered. Of the total mortality among
the babies under one year, only one-ninth of the number
were registered at the dispensary. Of this number the great-
est mortality was among those who were brought to the dis-
pensary in a dying condition.
V. The medical director of The Babies' Dispensary is director of
the Bureau of Child Hygiene. The superintendent of The
Babies' Dispensary is superintendent of nurses of the Bureau
of Child Hygiene.
The Babies' Dispensary supplies milk for the Board of
Health dispensaries and the Board of Health Prophylactic
Dispensaries send their babies to the Central Babies' Dispen-
sary.
VI. There is a close cooperation between this Association and other
welfare work in the city.
VII. We include prenatal work only to a limited degree. One branch
dispensary has regular classes. The nurses give talks to the
mothers in the district. Results have been seen in a marked
improvement in the mothers' care of their babies, especially
in nursing of the babies for a longer period of time.
VIII. and IX. We have 14 Board of Health Prophylactic Dispensaries.
One central dispensary for ill infants,
Instruction is given in general hygiene and special indi-
vidual care.
Individual talks are given to the mothers by physicians in
the dispensary and nurses in the home and nursing care of the
sick babies.
Our work includes the distribution and sale of milk.
X. Our staff consists of physicians, 14 Board of Health ; 6 Central
Dispensary. Nurses, 32 Board of Health; 5 Central Dispen-
sary.
XI, We depend upon private contributions for our support.
H. J. GERSTENBEBGEB, Medical Director.
AFFILIATED SOCIETIES 413
THE VISITING NURSE ASSOCIATION OF CLEVELAND
All infant welfare work in Cleveland is done through the special
branches, i. e., all prenatal work is done through the Maternity Asso-
ciation and all post-partum work by the Babies' Dispensary and Hospi-
tal, with the exception of a very few cases, comparatively speaking,
which we handle for private physicians and which are really not in a
sociological class.
BLANCHE SWAINHABDT, Acting Superintendent.
THE VISITING NURSE ASSOCIATION OF CINCINNATI
THE CHILDREN'S CLINIC
The "Children's Clinic" of the Ohio Miami Medical College of the
University of Cincinnati, has been in existence twenty-five years, and
was until three years ago conducted just as the other clinics of the
college were regarded, we may say, purely as a means of instruction.
Children under fourteen years of age might come for medical treat-
ment, but the child as an individual of the family as a whole received
but scant consideration.
For a number of years the Board of Health has during the summer
months established throughout the city stations for the distribution of
pure milk for infant feeding
In 1909 through the physician, then health officer, one of these
stations was opened at the "Children's Clinic," a deaconess volunteer-
ing to give two hours each day that the milk might be wisely distri-
buted.
In January, 1910, Dr. B. K. Rachford, pediatrician in charge of the
Children's Clinic, seeing the wonderful possibilities of the clinic, was
able to interest one of Cincinnati's public-spirited women to the extent
of furnishing funds sufficient to employ a graduate nurse to super-
intend the distribution of the milk and to be present during clinic
hours. Through this fund it was also possible to sell the milk at three
cents a pint, and in cases of destitution and real need to give it free
of cost. This policy has held until the present time; however, it has
often seemed that it might be wiser and, perhaps, a better plan, if the
milk were sold at four cents, the price paid for milk at any grocery
store, or even for four and one-half cents, the actual cost of the cer-
tified to us, the money going each month to make up a heavy deficit
might thus be saved and used in furthering the work along more help-
ful lines, and better still, the milk might then be valued more for its
true worth than because it is cheap, as I fear it ofttimes is, that which
is too easily acquired, as we all well know, is but seldom appreciated,
and what family is not better for having made sacrifices for its
younger members, and so, beginning November 1st, I've been told we
may try this theory out, and if the work continues to flourish with the
milk at four cents four cents it will remain.
In January of 1911 the nurse was put on full time, adding to her
original duties instruction in the homes. At this time cooperation
with the Cincinnati Maternity Society was established, all babies
being referred by the nurse of the Maternity Society at the time of
dismissal to the clinic nurse, and given what supervision was possible
for one nurse to give.
414 REPORTS
Incidentally, the work of the Maternity Society has grown mater-
ially since that time. Two nurses are now assigned and excellent pre-
natal care given all cases from the time of their acceptance. Normal
cases are visited daily for ten days after delivery, and usually twice
between then and the end of the month, when they are dismissed to us.
Through the clinic many of these babies have been kept on breast-
feeding at great odds. In a number of instances milk has been supplied
for the mother's own use when no other solution of the problem seemed
possible.
The nurses of the Maternity Society cooperate so closely with us of
the clinic we being all of the staff of the "Visiting Nurse Associa-
tion" that our work is greatly simplified by their instructions preced-
ing ours. We have the confidence of these mothers from the beginning.
The Social Service Department of the City Hospital also reports to
us babies under two years upon dismissal, especial stress being put
upon any case needing feeding supervision.
In February, 1912, a second nurse was added to the clinic staff, and
since May last we number three.
To the clinic, of course, come any children under fourteen years.
This is made necessary by the fact that none of our hospitals have
out-patient departments, but through the Visiting Nurse Association
we are able to confine our work almost exclusively to babies; older
children who need care in the home are reported to the Visiting
Nurse Association and cared for by the nurse in whose district the
case may be.
In November, 1912, we opened our first Infant Welfare Station in the
basement of Christ Episcopal Church, this for babies under two years
of age and prophylactic only, sick babies requiring more than a feed-
ing formula being referred to the main clinic.
One of our best clinicians volunteered to conduct the weekly confer-
ences, giving an hour each Thursday afternoon. The nurse working in
that district was in charge. On conference day she had the mothers
bring the babies in early and made an effort to have all weighing
done and charts in order before the doctor's arrival that she might
then be able to go over each case with him.
The distribution of certified milk from here was simplified by the
cooperation of the company supplying milk to the clinic. One of their
branch stores was but a block distant and tickets might be redeemed
here that were sold by the nurse at conference in numbers sufficient
to cover a week's supply, and at four cents a pint.
The work of this station proved interesting and successful, but owing
to the fact of an older agency having for several years conducted
a milk station through the summer months in this same neighborhood,
we closed this station early in June.
Through the courtesy of the Board of Education we immediately
opened another station in a public school building in the lower West
End a most congested and destitute section of the city.
The work here is conducted identically as it was in the first station,
and again a branch store of our milk concern is quite near.
During the summer a nurse was assigned to us by the Health De-
partment to work from this station ; both she and our nurse who is in
charge did excellent work here during an unusually hot summer.
The attendance at this station has from the first exceeded the at-
tendance had at the other, owing in a great measure to the congested
locality. One hundred and seven individual cases are now registered
here, and the total attendance to date is three thundred and twenty-
seven.
AFFILIATED SOCIETIES 415
Twelve clinicians constitute the medical staff at the main clinic, with
Dr. B. K. Rachford as director. The services are divided into terms
of four months, six physicians on each service.
Two are present each afternoon from four o'clock until six, if neces-
sary, but no patients are admitted after five o'clock.
Senior students from the college are assigned to the clinic, and the
splendid opportunity for observation and instruction is perhaps as
far reaching in its benefit to humanity as the welfare work of physi-
cians and nurses.
A most valuable asset to our work during the past year is a woman
physician, a recent graduate, working voluntarily as visitor.
We now feel this so indispensable that in a short time we hope it
may be established as a permanent position with salary attached.
Just a word as to records, for without them we know that work,
however good or worthy it may be, lives but today; however, when
workers are few, it is not always easy to decide between actual work
and records, when it is not possible to give accurate attention to both.
As yet our records leave much to be desired, but out of chaos is
slowly evolving a system that I think may in time give facts and fig-
ures of lasting value. The temperament of a nurse is seldom that of
a good bookkeeper, and until work of this sort is sufficiently financed
to make possible a purely clerical worker, all things cannot be hoped
for in the matter of records, and quite as much patience as zeal is
demanded of pioneers everywhere.
ADA S. STOKES, Supervisor of Nurses.
PENNSYLVANIA
THE CHILD FEDERATION OF PHILADELPHIA
(Formerly The Child Hygiene Association)
The Child Committee, the forerunner of the Child Hygiene Associa-
tion, was organized February 26th, 1912. On February 27th, 1913, it
was reorganized with the title "The Child Hygiene Association." Its
work as heretofore related entirely to the study and prevention of
infant mortality. The activities pursued by the Association should
be classed as :
(1) Research work
(2) Educational work
A Baby Saving Show was conducted in Horticultural Hall in 1912
with an attendance of 67,507 people. Eleven neighborhood baby saving
shows have been conducted with a total attendance of 124,739 people.
A report has been printed, showing the method and procedure fol-
lowed in the organization and operation of the baby saving show. This
report has been sent to medical men, health officers and social workers
all over the world. Active work has been carried on with the Depart-
ment of Public Health and Charities. This work has been done by
means of conferences, revising of literature published by the depart-
ment, and advice. Surveys have been made or are under way, covering :
(1) Municipal recreation piers
(2) Municipal nurses
(3) Municipal out-of-door physicians
(4) Division of child hygiene
416 REPORTS
Other surveys liave been made, covering:
(1) Hospital provisions for infants and children
(2) Day nurseries
(3) Ice cream and candy venders
A pamphlet, entitled "The Care of the Baby," has been published
and widely circulated. The past summer a Summer Baby Saving Show
has been conducted in the City Hall. The estimated attendance of
this show is 31,200 people. Thousands of copies of health literature
have been distributed. Lectures on health questions have been given.
Two model Little Mothers' Leagues have been conducted during the
past summer.
On September 30, 1913, the Child Hygiene Association received its
charter as the Child Federation. From now on the work of the Asso-
ciation will be vastly widened. The entire work of the Association has
been done and will be done by volunteers.
ALBERT CROSS, Managing Director.
CHILDREN'S AID SOCIETY OF PENNSYLVANIA
Philadelphia
The following is a brief statement of the operation of the depart-
ments of the Children's Aid Society of Pennsylvania, which has to do
with the care of young infants.
The Children's Aid Society of Pennsylvania maintains a special
department to prevent the separation of destitute mothers from their
children. In 1912 the applications included 262 women with children
cared for in the I>epartment for Women with Children, 238 mothers
each with one child, 8 with two children, and 16 without children. For
abandoned infants and for others whose mothers are for some reason
unable to nurse them, the Society has established a system of wet
nursing. We give below a brief account of the work done during 1912.
The Weekly Eoster of the medical organization of Philadelphia for
March 30, 1912, made the following announcement of the work of the
Children's Aid Society in securing wet nurses for neglected children.
"In addition to many other useful public functions, a directory and
registration bureau for wet nurses is being established by the Chil-
dren's Aid Society of Pennsylvania in its building, 419 South Fifteenth
Street. The Society has undertaken this work in order to secure wet
nurses for young babies for whom it is asked to provide such care on
the recommendation of doctors connected with hospitals and charitable
agencies. In addition, the Society hopes to keep on hand a list of cer-
tified wet nurses who may be employed by doctors for their private
patients. The wet nurses and their babies are examined by a doctor
and no one will be recommended who has not passed the various tests
required to provide every safeguard for both the wet nurse and the
baby. When two babies are being cared for by the same wet nurse pre-
cautions are taken to see that both are properly nourished. The man-
agement will be glad to have doctors refer to the above address any
women who desire to obtain a position as wet nurse. Assistance is
also solicited in helping to make known the existence of this directory
and registration bureau. Further information can be obtained by com-
municating with the Society at the above address."
In April, 1912, at a joint meeting of the Philadelphia Pediatric Soci-
ety and the Philadelphia Obstetrical Society, a resolution was passed
AFFILIATED SOCIETIES 417
endorsing the effort of the Children's Aid Society, a Society to estab-
lish a directory and registration bureau for wet nurses.
Before undertaking this new work the Children's Aid Society held
a number of conferences attended by representatives of various hos-
pitals and charitable agencies dealing with young infants. This new
department was really established in response to their requests and in
cooperation with these agencies.
From March 1, 1912, to the end of the year a total of 31 nursing
babies were received and cared for. Their average age when received
was three months. Seventeen of these came from the alms house at
Blockley through the Department of Public Health and Charities, and
included babies abandoned on the street by mothers, and others whose
mothers had died or were sent for some reason to a public institu-
tion on account of physical or mental defects. Seven infants were
taken through the social service department of hospitals on account
of the death or illness or other incapacity of the mother to nurse and
care for her own baby ; one was received from the United Hebrew
Charities because the mother had died; another motherless infant came
from the Coal Township Poor District of Northumberland County;
while four were received from parents on account of the physical
condition of the mother.
At the close of the year 1912, of the 31 infants received in this
department, 12 were with wet nurses. The average length of time
these 31 infants remained with wet nurses was four months, and the
average gain in weight was three pounds and two ounces. Some of
these infants were cared for temporarily and eventually returned to
their mothers, while others were transferred to our country boarding
homes or placed with a view to adoption. A few had to be returned
to hospitals on account of illness, and 3 died in our care, having been
in a very delicate condition when received.
The experiment has shown the value of wet nursing in the reduc-
tion of the death rate. It was successfully tried for many of these
babies as a last resort after other methods of feeding had failed to
improve their condition. Some of the babies were in such a delicate
condition that it is altogether probable that they would not have sur-
vived except for this method of care. However, there is a question
as to the extent to which the needs of the community can be met
by boarding out infants in homes of wet nurses. Apparently there is
an important field for the use of wet nurses by hospitals and institu-
tions. The Children's Aid Society is chiefly interested in helping to
establish this method as far as possible for foundlings and other deli-
cate infants whose mothers are physically unable to care for them.
In addition to this work, the Children's Aid Society maintains a
boarding-out department for infants after they have passed the nursing
stage, and also for older children.
EDWIN D. SOLENBERGEB, General Secretary.
RHODE ISLAND
PROVIDENCE DISTRICT NURSING ASSOCIATION CHILD WELFARE
SERVICE
The Providence District Nursing Association has six nurses specially
employed in child welfare work all the year round. One or two addi-
tional nurses are employed during the summer. The work was started
as a special service in 1908.
418 REPORTS
Prenatal work is not done as yet as a special branch, but much in-
struction and advice is given to pregnant mothers.
There is close cooperation with the various agencies dealing with
children, particularly the Rhode Island Hospital, the Lying-in Hospital
and the City Board of Health.
All babies leaving the infant ward of the Rhode Island and all
mothers leaving the free ward of the Lying-in Hospital are auto-
matically visited by the nurses, while all licensed boarding houses for
babies are regularly inspected and visited by the nurses at least once
a week at the request of the Board of Health.
All mothers delivered by midwives are visited by a nurse employed
by the City Board of Health and the mothers needing further instruc-
tion are handed on to the children's nurses of the Providence District
Nursing Association.
During the past year 2,534 cases were visited and 20,149 visits
were made. This number includes children up to five years of age,
though about three-fifths are infants under two.
Instruction is given by the nurses in the homes, at clinics and well
babies' consultations and in school talks to mothers.
Obstetrical service is given by the Providence District Nursing Asso-
ciation, but by other nurses than those doing welfare work.
There are, besides the hospital clinics, three well babies* consulta-
tions held weekly and one for sick and well babies. A doctor is
present and instruction is given by botfc doctor and nurses, baby clothes
being shown. No milk is distributed or sold.
The death rate for children under five from 1908 is as follows:
1908 1,100
1909 1,079
1910 1,179*
1911 921
1912 908
The nurses reach about one-twelfth of the children of the city under
five. The work is financed by voluntary contributions.
* Epidemic of infantile paralysis.
MARY S. GABDNER, Superintendent.
TEXAS
HOUSTON SETTLEMENT ASSOCIATION
The Houston Settlement Association has a summer camp for sick
babies. Forty-six babies were cared for during the four months the
camp remained open.
MBS. FRANK ANDREWS, First Vice-president.
VIRGINIA
BOARD OP HEALTH
Richmond
I. The registration of births is of very great value in the work of
this department.
II. During 1912 nearly 40 per cent of the infant population of
Richmond have been visited and cared for by our nurses.
AFFILIATED SOCIETIES 419
III. This work is carried during the entire year.
IV. The Department of Health first undertook tins work in March,
1910.
VII. We include only a limited amount of prenatal work with our
postnatal care.
IX. We have no welfare stations. Visits are made by the nurses
to the mothers in their own homes, where instructions are
given on the care of babies, as well as nursing care of sick
babies. We do not distribute or sell milk
X. There are five nurses on our staff. We do not supervise ill
babies, not regarding this as strictly health department work.
We have no doctor in this splendid work. Our medical de-
partment is always available, however.
XI. The work is financed by the city.
B. C. LEVY, M. D., Chief Health Officer.
AMERICAN ASSOCIATION FOB STUDY AND PREVENTION OF
INFANT MORTALITY
MEMBERSHIP LIST 1913
Honorary
France
Bertlllon, Dr. Jacques Paris
GENERAL MEMBERSHIP
LIFE MEMBERS
Ford, Miss Stella D., Detroit, Michigan
Gitchell, Miss Katherine, Akron, Ohio
Hanna, Mr. and Mrs. H. M., Cleveland, Ohio
Holt, Dr. L, Emmett, New York City
Knox, Mrs. J. H. Mason, Jr., Baltimore, Md.
Knox, Miss Katherine Bowdoin, Baltimore, Md.
Knox, J. H, Mason, 3rd, Baltimore, Md.
Mellon, Mr. A. W., Pittsburgh, Pa.
Oliver, Mr. Wm. B., Baltimore, Md.
Shevlin, Mrs. Thomas, Minneapolis, Minn.
Volker, Mr. Wm., Kansas City, Mo.
Wade, Mr. and Mrs. J. H., Cleveland, Ohio
White, Mr. R. J., Baltimore, Md.
AFFILIATED SOCIETIES
Babies' Dairy Association, New York City
Babies' Dispensary Guild, Hamilton, Ontario, Canada
Babies' Dispensary and Hospital, Cleveland, Ohio
Babies' Hospital, New York City
Babies' Hospital, Newark, N. J.
Babies' Hospital Milk Dispensary, Newark, N. J.
Babies' Milk Dispensary, Buffalo, N. Y.
Babies' Milk Fund Association, Detroit, Michigan
Babies' Milk Fund Association. Louisville, Kentucky
Baby Welfare Committee, of uttca, N. Y.
Baby Welfare Section of Civic Club of Cumberland, Md.
Baltimore Association of Jewish Women, Baltimore, Md.
Berlin Mills Company's District Nurse, Berlin. N H.
Bureau o-f Charities District Nursing Committee, Brooklyn, N. Y.
Bureau of Municipal Research, Dayton, Ohio
Bureau of Municipal Research, New York City
Camp Fire Girls of America, New York City
Certified Milk and Baby Hygiene Committee, California Association of Collegiate
Alumnae, San Francisco, Cal.
Charity Organization Society, Grand Rapids, Michigan
Child Federation, Philadelphia, Pa.
Child Welfare Association, New Orleans, La.
Child Welfare Committee of the Red Cross, Burlington, Iowa
Childrens' Aid Association, Indianapolis, Ind.
Childrens' Aid Society, Brooklyn, N. Y.
Childrens* Aid Society of Pennsylvania, Philadelphia
420
MEMBERSHIP LIST 421
s ' Fre ? Dispensary and Hospital Association, South Bend, Indiana
Christian Service League of America, Wichita, Kansas
Clinic for Infant Feeding of the D. A. Blodgett Home, Grand Eapids, Michigan
Committee on Infant Social Service of the Womens' Municipal League, Boston,
Massachusetts
Connecticut Childrens' Aid Society, Hartford, Conn.
Council, Milk and Ice Fund, Baltimore, Md.
Day Nursery and Free Kindergarten Association, Cleveland, Ohio
Department of Home Economics, N. Y. State College of Agriculture, Ithaca, N. Y.
Diet Kitchen of the Oranges, Orange, N. J.
Houston Settlement Association, Houston, Texas
Infant Aid Association, Manchester, N. H.
Infant Mortality Association, Birmingham, Ala,
Infant Welfare Association, New Haven, Conn.
Infant Welfare Committee, Syracuse, N. Y.
Infant Welfare Department, Duluth Consistory Scottish Rite Masons, Duluth,
Minn.
Infant Welfare Society of Chicago, 111.
Infant Welfare Society of Minneapolis, Minn.
Infant Welfare Station, La Salle, Illinois (Emma Matthieson Chancellor
Memorial)
Ladies' Literary Club of Salt Lake City, Utah
Maryland Association for Study and Prevention of Infant Mortality (Babies'
Milk Fund Association) Baltimore, Md.
Maryland Society for the Prevention of Blindness, Baltimore, Md.
Massachusetts Babies' Hospital, Boston, Mass.
Massachusetts Milk Consumers' Association, Boston, Mass.
Maverick Dispensary, Boston, Mass.
Metropolitan Life Insurance Company, Industrial Department, New York City
Milk and Baby Hygiene Association, Boston, Mass.
Milwaukee Maternity Hospital and Free Dispensary Association, Milwaukee, Wis.
Mothers' Aid of the Chicago Lying-in Hospital and Dispensary, Chicago, 111.
New Orleans Pure Milk Society, New Orleans, La.
New York Diet Kitchen Association, New York City
New York Milk Committee, New York City
Public Library, Providence, R I.
Race Betterment Conference, Battle Creek, Michigan
St. Louis Children's Hospital, St. Louis, Mo.
St. Louis Pure Milk Commission, St. Louis, Mo.
St. Margaret's House and Hospital, Albany, N. Y.
Society for Helping Destitute Mothers and Infants, Boston, Mass.
Sub-Committee on Mothers and Infants, New York State Charities Aid Associa-
tion, New York City
Utah Congress of Mothers, Salt Lake City
Woman's Club, Chicago, Illinois
Woman's Club, Decatur, Illinois
Alumna Association Battle Creek Sanitarium Training School for Nurses, Battle
Creek, Michigan
American Nurses' Association, New York City
Columbus (Ohio) District Nursing Association
Farrand Training School Alumnae Association, Detroit, Michigan
Georgia State Association of Graduate Nurses
Maryland State Association of Graduate Nurses
Missouri State Nurses' Association
National League of Nursing Education
Nebraska State Association of Graduate Nurses
New York State Nurses' Association
Ohio State Association of Graduate Nurses
Providence District Nursing Association, Providence, R. I.
Visiting Nurse Association, Cincinnati, Ohio
Visiting Nurse Association, Cleveland, Ohio
Visiting Nurse Association, Detroit, Michigan
Visiting Nurse Association, Elizabeth, N. J.
Visiting Nurse Association, Eau Claire, Wisconsin
Visiting Nurse Association, Milwaukee, Wisconsin
Visiting Nurse Association, Waterbury, Conn.
Board of Health, Richmond, Va.
Bureau of Health, Rochester, N. Y.
Division of Child Hygiene, Department of Health, Milwaukee, Wia.
Health Department, Baltimore, Md.
State Board of Health, Jacksonville, Florida
State Board of Health, Raleigh, N. C
422 MEMBERSHIP LIST
GENERAL MEMBERSHIP
Argentine Republic
Vidal, Dr. Antonio t . 2169 Juncal St., Buenos Aires
China
Hume, Dr. Edward H The Yale Hospital, Changsha
Magee, Mr. John G Nanking
Engrlaiid
Broadbent, Aid. Benjamin Gatesgarth, Lindley, Huddersfield
Lane-Claypon, Dr. Janet IS Craven Terrace, Lancaster Gate, \V.
London
Perkins, Dr. J. H Tbe Hydro, College Green, Bristol
New Zealand
Campbell, Miss Annie D Karitane-H arris Hospital, Anderson's
Bay, Dunedin
Jenkins, Mr. William 85 Cumberland St., Dunedin
Scotland
Boyd, Mr. T. Hunter 70 Bothwell St., Glasgow
Syria
Dorman, Dr. Harry G Syrian Protestant College, Beyrout
Moore, Prof. Franklin American College, Beirut
Canada
Babies' Dispensary Guild (Affil.) 12 Euclid Ave., Hamilton, Ontario
Blackader, Dr. A. D 236 Mountain St., Montreal
Dyke, Miss E. H Superintendent of Visiting Nurses, Do-
. partment of Health, Toronto, Ontario
McCullough, Dr. John W Secretary Provincial Board of Health,
Toronto, Ontario
MacMurchy, Dr. Helen 133 East Bloor St., Toronto
Mackay, Miss Mary A 1414 7th Ave., S., Lethbridge, Albcrtu
Moody, Dr. A. W 430% Main St., Winnipeg, Manitoba
Pelletier, Dr. Elzear Secretary Board of Health, Province of
Quebec, Montreal
Wilson, Miss Prederica Lady Superintendent Winnipeg General
Hospital Training Schools for Nurses,
Manitoba
Wodehouse, Dr. Robert Elmer Provincial Board of Health, Fort Wil-
liam, Ontario
Hawaii
Pratt, Dr. John, S. B P. o. Box 086, Honolulu
Philippine Islands
Pond, Dr. Eleanor J The Mary Johnston Hospital, Manila
Alabama
Huggins. Mrs. Augusta Talladega
Infant Mortality Association (Affll.) . . .526 Chamber of Commerce Building,
Birmingham
Parke, Dr. Thomas D 415 First National Bank Building, Bir-
mingham
Phelan, Miss Sarah E 1330 14th Ave., S., Birmingham
MEMBERSHIP LIST 423
California
Ainley, Dr. Prank C 715 Wright and Callender Building, Los
Angeles
Ash, Dr. Rachel L Galen Building, San Francisco
Brown, Dr. Adelaide 240 Stockton St., San Francisco
Certified Milk and Baby Hygiene Com-
mittee, Association of College
Alumnae (Affil.) San Francisco
Earl, Miss Alice 2914 McClure St., Oakland
Fleischner, Dr. E. C 350 Post St., San Francisco
Goethe, Mr. C. M Inverness Building. Sacramento
Graupner, Mrs. A. E 2009 Jackson St , San Francisco
Gray, Mr. R. S Commonwealth Club, 153 Kearney St.,
San Francisco
Haynes, Dr. John Randolph 429 Consolidated Realty Building, Los
Angeles
Jenkins, Mr. H. O Palo Alto
King, Dr. Charles Lee 70 S. Euclid Ave., Pasadena
Lucas, Dr. Wm. Palmer University of California Hospital, San
Francisco
McBride, Dr. J. H 489 Bellefontaine St., Pasadena
McCleave, Dr. Thomas C 2844 Garber St., Berkeley
Moffitt, Dr. Herbert C 240 Stockton St., San Francisco
Powers, Dr. L. M Commissioner of Health, 1022 North
Alvarda St., Los Angeles
Porter, Dr. R. Langley San Francisco*
Powell, Dr. Thomas 313 West Third St., Los Angeles
Slemons, Dr. J. Morris 3404 Clay St., San Francisco
Tevis, Mrs. Wm. S Box 747, Bakersfleld
Thum, Mr. William Pasadena
Willitts, Dr. Emma K Galen Building, San Francisco
Colorado
Gengenbach, Dr. Frank P 1434 Glenarm Place, Denver
Titsworth, Mr. Frederick S Equitable Building, Denver
Whitney, Dr. H. B 320 Temple St., Denver
Connecticut
Bartlett, Mrs. C. J 209 York St., New Haven
Bennett, Mrs. Winchester 76 Everit St., New Haven
Bronson, Miss Margaret L 1198 Chapel St., New Haven
Carle, Mr. Robert W I*. O. Drawer D, New Haven
Carmalt, Dr. W. H 261 St. Roman St., New Haven
Connecticut Children's Aid Society
(Affil.) 60 Brown-Thomson Building, Hartford
Fisher, Prof, and Mrs. Irving 460 Prospect St., New Haven
Goodcnough, Dr. E 1 W 44 Leavenworth St , Waterhury
Goodrich, Dr. Charles A 3 Haynes St., Hartford
Gregory, Mrs. A. W 63 Gillett St., Hartford
Hillyer, Mrs A. It 91 Elm St., Hartford
Infant Welfare Association of New
Haven (Ami.) 301 Prospect St., New Haven
Linde, Dr. Joseph 1 163 York St., New Haven
Mead, Dr. Kate C 165 Broad Si, Middleto-wn
Stanley, Mr. A. W P. 0. Box 704, New Britain
Steele, Dr II Merrirnan 226 Church St., New Haven
Steiner, Dr. W- R 4 Trinity St., Hartford
Wanning, Mr. F. D Derby
Waterbury Visiting Nurse Association
(Affil.) 37 Central Ave., Waterbury
Wilkinson, Miss Martha J 34 Charter Oak Ave., Hartford
District of Columbia
Adams, Dr. Samuel S 1 Dupont Circle, Washington
Boyd Dr. George W 121 Second St., N. W., Washington
Brickenstein, Mr. J. H 918 F St., Washington
Columbia and Children's Alumnae As- ^ T
sociation (Affil.) 1337 K St., N. W., Washington
Dickinson, Mrs. H. C 30th St., Azadia Park, Washington
Flannery, Mrs. John S 2017 O St., N. W., Washington
4:24 MEMBERSHIP LIST
Fremont-Smith, Dr. F 1808 Massachusetts Ave., Washington
Gardner, Miss Helen W , R. N The Portner, Washington
Green, Mr. Bernard R Library Building, Washington
Gwynn, Miss Mary 1740 N St., N. W., Washington
Hammond, Mrs, John Hays 2315 Massachusetts Ave., Washington
Hay, Mrs. John 800 Ave. of the Presidents, Washington
Heald, Mrs. Edward C 1617 Riggs Place, Washington
Heurich, Mrs. Christian 1307 New Hampshire Ave., Washington
Instructive Visiting Nurse Society
(Ami.) 2506 K St., N. W., Washington
Kober, Dr. George M 1819 Q St., N. W., Washington
Langworthy, Mr. Charles Ford Department of Agriculture, Washington
Lathrop, Miss Julia C., Chief Federal Children's Bureau, Washington
Lewis, Mrs. Fulton 1669 31st St., Washington
*Magruder, Dr. G. Lloyd Stoneleigh Court, Washington
Nagel, Mrs. Charles 1731 K St., Washington
Nevins, Miss Georgia M., Supt Garfield Memorial Hospital, Washington
Newton, Mrs. Elsie Eaton, Supervisor . . U. S. Indian Service, Washington
Overton, Mrs. W. S 2 Dupont Circle, Washington
Perkins, Mrs. Henry Cleveland 1701 Connecticut Ave., Washington
Pfender, Dr. Charles A 304 Rhode Island Ave., N. W., Wash-
ington
Seville, Miss Catherine 1420 17th St., N. W., Washington
Schereschewsky, Dr. J. W Hygienic Laboratory, Washington
Skinner, Dr. J. 0., Supt Columbia Hospital for Women, Wash-
ington
Stetson, Rev. C. R St Mark's Church, 301 A St., S. B.,
Washington
Strong, Miss Isabel 2001 I St., N. W., Washington
Van Schaicfc, Rev. John R., Jr., 1417 Massachusetts Ave., N. W., Wash-
ington
Wilbur, Dr. Cressy L Bureau of the Census, Washington
Wilbur, Mrs. Cressy L 1374 Harvard St.. Washington.
Wilson, Mrs. Huntington 1608 K St., Washington
Woodward, Dr. Wm. C 1766 Lanier Place, Washington
Florida
State Board of Health (Affil.) Jacksonville
Georgia
Boyd, Mrs. Emma Garrett 194 Washington St, Atlanta
Funkhouser, Dr. W. L Rome
Georgia State Association of Grad-
uate Nurses (Affil.) Augusta
Rhodes, Dr. C. A .Atlanta
Illinois
Abt, Dr. Isaac A 4S10 Kenwood Ave., Chicago
Addams, Miss Jane Hull House, Chicago
Ahrens, Miss Minnie H 946 W. Adams St., Chicago
Alexander, Dr. W. G 1604 Chicago Ave., Evanston
Amberg, Dr. Samuel Children's Memorial Hospital, Chicago
Atkinson, Mrs. Charles Lake Forest
Bailey, Mr. Edward P Chicago Savings Bank and Trust Con>
pany, Chicago
Ball, Dr. Charles B Department of Health, Chicago
Beifeld, Dr. Albert Henry 31 North State St., Chicago
Bell, Mrs. Laird 31 Scott St, Chicago
Bowen, Mrs. Louise de Koven 1430 Astor St.. Chicago
Breckenridge, Dr. S. P University of Chicago, Chicago
Breeze, Miss Jessie 3518 Congress St., Chicago
Brockett, Miss Myrn 818 Ewing St., Chicago
Burling, Mrs. Edward Hubbard Woods
Casselberry, Mrs. Lilian H 1830 Calumet Ave., Chicago
Chancellor, Dr. Philip S Lessing Annex, Chicago
Chander, Dr. Harriet Day 233 S. Edward St., Decatur
Churchill, Dr. F. S 1259 N. State St., Chicago
DeLee, Dr. J. B 5028 Ellis Ave., Chicago
Dunn, Mrs. Morrill . . 125 E. Chestnut St, Chicago
Evans, Dr. W. A The Chicago Tribune, Chicago
* Deceased
MEMBERSHIP LIST 425
Farwell, Mrs. Fanny D Lake Forest
Fulmer, Miss Harriet 5329 Lake Ave., Chicago
Grulee, Dr. Clifford G 3974 Lake Ave., Chicago
Hay, Mrs. W. L oSOO Michigan Ave., Chicago
Hedger, Dr. Caroline 29 B. Madison St., Chicago
Heinemann, Dr. Paul G University of Chicago, Chicago
Helmholz, Dr. Henry F 1630 Ashland Ave., Evanston
Henderson, Prof. Charles Richmond. .. .University of Chicago, Chicago
Henderson, Mrs. Charles Richmond. . . Chicago
Hess, Dr. Julius H 5514 Indiana Ave., Chicago
Hey worth, Mrs. James Lake Forest
Hilton, Mr. Henry H 2301 Prairie Ave., Chicago*
Infant Welfare Society of Chicago
(Affil.) 104 S. Michigan Ave., Chicago
Infant Welfare Station (Emma Mat-
thiessen Chancellor Memorial) (Affil ) .La Salle
Johnstone, Miss Margaret E., R. N St. Luke's Hospital, Chicago
Jones, Miss Gwethalyn Lake Forest
Jordan, Prof. Edwin University of Chicago, Chicago
Kingsley, Mr. Sherman C 315 Plymouth Court, Chicago
Kirk, Mrs. Walter 76 E. Cedar St., Chicago
Lathrop, Mr. Bryan 407 S. Dearborn St., Chicago
Lewis, Mr. E. H Lewis Institute, Chicago
McCormick, Mr. Harold F Chicago Stock Exchange Bldg., Chicago
McCormick, Mrs. Harriet H 50 E. Huron St., Chicago
McCormick, Mrs. Medill 500 Diversey Parkway, Chicago
Meyer, Mr. Alfred C 843 W. Adams St., Chicago
Michael, Dr. May 1625 Prairie Ave., Chicago
Milligan, Dr. Josephine 610 W. State St., Jacksonville
Mothers' Aid of the Chicago Lying-in
Hospital and Dispensary (Affll.) Chicago
Palmer, Mrs. Robert F 2634 Lake View Avo , Chicago
Poole, Mrs. R. H Elsinore, Lake Forest
Rew, Mrs. Irwin 1128 Ridge Ave., Evanston
Rosenwald, Mr. Julius % Sears, Roebuck & Co , Chicago
Scott, Mrs. Frederick H 1332 Chicago Ave., Evanston
Scott, Mrs. Robert L 404 Lake St., Bvanston
Shaw, Mrs. Howard Van Doren Lake Forest
Teter, Mr. Lucius 5637 Woodlawn Ave., Chicago
Towne, Mrs. John D 1004 Greenwood Blvd., Bvanston
Tyson, Mrs. Russell 20 E'. Goethe St., Chicago-
Walsh, Miss Adelaide Children's Memorial Hospital, Chicago
Webster, Mrs. Edwin H Hubbard Woods
Webster, Dr. George W., President State Board of Health, Chicago
Woman's Club 410 S. Michigan Ave., Chicago
Woman's Club of Decatur 1033 N. Union St., Decatur
Wynekoop, Dr. A. Lindsay '406 W. Monroe St., Chicago
Young, Dr. George B Commissioner of Health, Chicago
Zimmerman, Mr. W. C ^teinway Building, Chicago
I udiana
Children's Aid Association (Affil.) 62-63 Baldwin Block, Indianapolis
Children's Dispensary and Hospital
Association (Aflfll.) 1031 W. Division St., South Bend
Mumford, Dr. E. B 504 Newton-Claypool Bldg., Indianapolia
Powell, Dr. Nettie B Marion
Rappaport, Mr. Leo M 822 Law Building, Indianapolis
Wiggam, Mr. A. B North Vernon
Iowa
Child Welfare Committee of the Red
Cross (Affll.) 502% Jefferson St., Burlington
Mcllvain, Mrs. M. P 1604 Dill St., Burlington
Shrbon, Dr. Florence Brown Colfax
Kansas
Christian Service League of America
(Affll.) 113 N. Lawrence Ave., Wichita
Crumbine, Dr. S. J State Board of Health, Topeka
Day, Miss Edna D Department of Home Economics, Uni-
versity of Kansas, Lawrence
Hosford, Mr. George Lewis 113 N. Lawrence Ave., Wichita
426 MEMBERSHIP LIST
Kentucky
Babies' Milk Fund Association (Affil.) . .215 E. Walnut St., Louisville
Barbour, Dr. Philip P Louisville T , __,
Belknap, Mrs. Morris A 1322 1 Fourth Ave., Louisville
Butler, Miss Harriet L W. C. T. U. Settlement School, Hind-
man, Knott Co.
Myer, Dr. Samuel Percival 216 W. Chestnut St., Louisville
Shaver, Miss Elisabeth 215 E. Walnut St., Louisville
Smith, Mrs. Letchworth Ann Acres, Mocking Bird Valley, R. F.
D. No 1, Louisville
Tuley, Dr. Henry Enos Ill W. Kentucky St., Louisville
Louisiana
Butterworth, Dr. W. W Mane University, New Orleans
Child Welfare Association (Affil.) 419 Gravier St., New Orleans
DeBuys Dr. L. R 1776 State St., New Orleans
Denegre, Mrs. George Prytania and Eighth Sts., New Orleans
Hart Mr. W. 134 Carondelet St., New Orleans
Her old, Mrs. S. L % Thigpen & Herold, First National
Bank Building, New Orleans
New Orleans Pure Milk Society (Affil.) .1206 Maison Blanche Bldg., New Orleans
Maine
Erb., Mrs. F. 110 Emery St., Portland
Everett, Dr. Harold J 727 Congress St., Portland
Gerrish, Dr. Y. H Portland
Webster, Dr. F. P Portland
Young, Dr. A. G., Secretary State Board of Health, Augusta
Maryland
Abel, Mrs. John J Charles St., ext, Baltimore
Abercrombie. Dr. Ronald T The Homewood Apartments, Baltimore
Athey, Mrs. Caleb N 100 S. Patterson Park Ave., Baltimore
Baby Welfare Section of Civic Club
(Affil.) Cumberland
Baltimore Association of Jewish
Women (Affil.) 2355 Eutaw Place, Baltimore
Barker, Mrs. L. F 1035 N. Calvert St., Baltimore
Beitler, Dr. Frederic V Bureau of Vital Statistics, State Depart-
ment of Health, Baltimore
Belt, Mrs. W. H. G 013 Reservoir St., Baltimore
Bliss, Mrs. Wm. J. A 1017 St. Paul St., Baltimore*
Bloodgood, Mrs. Joseph C 004 N. Charles St., Baltimore
Bonaparte, Mr. Charles J 210 St. Paul St., Baltimore
Bowdoin, Miss Alice G 865 Park Ave., Baltimore
Bowdoin, Mrs. W. G 1106 N. Charles St., Baltimore
Buck, Mrs. R. B 1228 St. Paul St., Baltimore
Carey, Mrs. Francis K 309 Cathedral St , Baltimore
Carman, Dr. R. P 1701 N. Caroline St., Baltimore
Cochran, Mr. and Mrs. Wm. F., Jr \Voodbrook
Cone, Dr. Claribel The Marlborough, Baltimore
Cook, Mrs. George Hamilton 1001 St. Paul St., Baltimore
Corkran, Mrs. Ben;}. W., Jr 200 Goodwood Gardens, Roland Park
Council, Milk and Ice Fund (Affil.) .... Baltimore
Davis, Mrs. John Staige 1200 Cathedral St., Baltimore
Dobbin, Mrs. Thomas M 1308 Bolton St., Baltimore
Dorsey, Mrs. John R 730 Roland Ave., Baltimore
Ellicott, Mrs. Charles Melvale
Epstein, Mr. Jacob 2532 Eutaw Place, Baltimore
Etchberger, Miss M. Frances 3602 Park Heights Ave., Baltimore
Follis, Dr. Richard H .'{ E. Road St , Baltimore
France, Mrs. J. C 210 W. Lanvalc St, Baltimore
French, Miss Anna M 219% E. North Ave., Baltimore
Friedenwald. Dr. Julius 1013 N Charles St., Baltimore
Fulton, Dr. John S., Secretary State Department of Health, Baltimore
Garrett, Mr. Robert Oarrott Building, Baltimore
Gibbs, Mr. John S., Jr 1026 N Calvert St, Baltimore
Gibbs, Mrs. Rufus M.... 1214 N. Charles St, Baltimore
Gilpin, Mrs. Henry B Baltimore
Gorter, Dr. Nathan R 1 W. Biddle fit., Baltimore
MEMBERSHIP LIST 427
Greenbaum, Dr. Harry S Itil4 Butaw Place, Baltimore
Guggenheimer, Miss Aimee -30 Talbot Road, Windsor Hills
Hamburger, Mrs. Louis P 1207 Eutaw Place, Baltimore
Health Department (Affil,) Baltimore
Hecht, Mrs. Albert 2408 Eutaw Place, Baltimore
Heinemann, Mrs. Milton 2220 Eutaw Place, Baltimore
Hendley, Mrs. Charles W Homewood Apartments, Baltimore
Hochschild, Mrs. Max 1922 Eutaw Place, Baltimore
Hooker, Dr. Donald B Station H, Govans
Hooper, Mrs. Jas. E St. Paul and 23rd Sts., Baltimore
Howland, Dr. John Johns Hopkins Hospital, Baltimore
Hunner, Dr. Guy L 2305 St. Paul St, Baltimore
Jackson, Miss Mary Celeste 2810 Philadelphia Ave., Baltimore
Jacobs, Dr. Henry Barton 11 W. Mt. Vernon Place, Baltimore
Jencks, Mrs. Francis M 1 W. Mt. Vernon Place, Baltimore
Johnston, Mrs. Josiah Lee 1202 Eutaw Place, Baltimore
Jones, Dr. C. Hampson ^529 St. Paul St., Baltimore
Katz, Mrs. A. Ray 2532 Eutaw Place, Baltimore
Keyser, Mr. R. Brent Keyser -Building, Baltimore
Knipp, Master George W Athol Ave., Station D, Baltimore
Knipp, Miss Gertrude B 1821 Park Ave., Baltimore
Knipp, Dr. Harry E Fremont and Lanvale Sts., Baltimore
Knox, Dr. and Mrs. J. H. Mason, Jr. ... S04 Cathedral St., Baltimore
Knox, Miss Katherine Bowdoin 804 Cathedral St., Baltimore
Knox, Master J. H. Mason, 3rd 804 Cathedral St., Baltimore
Koppelman, Mr. Charles H 1G W. Madison St., Baltimore
Lauer, Mrs. Leon 2024 Eutaw Place, Baltimore
Levering, Mr. Joshua 1310 Eutaw Place, Baltimore
Lichtenstein, Mrs. Francina Freese .... Cumberland
Lockwood, Dr. Wm. F 8 E. Eager St , Baltimore
MacMahon, Miss Amy E., R. N Johns Hopkins Hospital, Baltimore
McLanahan, Mr. Austin % Alex. Brown & Sons, Baltimore
Magruder, Mr. J. W 16 St. Paul St., Baltimore
Marburg, Mrs. Theodore 14 W. Mt. Vernon Place, Baltimore
Maryland Association for Study and
Prevention of Infant Mortality
(Affil.) 44 Bible Building, Baltimore
Maryland Society for the Prevention
of Blindness (Affil.) 004 N. Charles St., Baltimore
Maryland State Association of Grad-
uate Nurses (Affil.) 1211 Cathedral St., Baltimore
Mitchell, Dr. Charles W ( .) E. Chase St., Baltimore
Murray, Mrs. Edward Elkridge
Nagle, Mr. Theo. H 07 American Building, Baltimore
O'Donovan, Dr. Charles 5 E, Read St., Baltimore
Oliver, Mr. Wm. B The Washington Apartments, Baltimore
Oppenheim, Mrs. Eli 2042 Eutaw Place, Baltimore
Pleasants, Dr. J. Hall SOG University Parkway, Baltimore
Poultney, Mrs. Wm. D Chattolanee
Price, Miss Amabel Lee Aigburth Park, Towson
Price Dr. Marshall L Baltimore
Ramsay, Mr. John B 1218 St. Paul St., Baltimore
Ruhrah, Dr. John Algonquin Apts., Baltimore
Semmes, Mrs. John E 10 B. Eager St., Baltimore
Seegar, Dr. and Mrs. J. K. B. E 1529 Park Ave., Baltimore
Sherwood, Dr. Mary The Arundol Apartments, Baltimore
Shoemaker, Mrs. Edward 1031 N. Calvert St., Baltimore
Shoemaker, Mr. S. M Eccleston
Sonneborn, Mrs. Sigmund B 2420 Eutaw Place, Baltimore
Swindell, Mr. C. J. B 4 Club Koad, Roland Park
Taylor, Mrs. A. H 4 E. Eager St., Baltimore
Thomas, Dr. Henrietta M 1718 John -St., Baltimore
Todd, Dr. Wm. J Mt. Washington
Urquhart, Dr. Richard A 48 W. Biddle St., Baltimore
Walker, Mrs. Amelia H 25 W. Chase St., Baltimore
Welch, Dr. Wm. H 807 St. Paul St., Baltimore
Welsh, Dr. Lilian The Arundel Apartments, Baltimore
Westheimer, Mrs. Henry 2322 Eutaw Place, Baltimore
White, Mr. B. D Crown Cork and Seal Co., Baltimore
White, Mr. Richard J 10 South St, Baltimore
Whitely, Mr. J. Holmes 1008 N. Charles St., Baltimore
Whitridge, Mrs, John Brooklandville P. 0.
4:28 MEMBERSHIP LIST
Whitridge, Mrs. Morris 818 University Parkway, Baltimore
Wight, Mrs. John H Garrison P. O.
Williams, Dr. J. Whitridge 1128 Cathedral St., Baltimore
Young, Dr. Hugh H 330 N. Charles St., Baltimore
Massachusetts
Arnold, Miss Sarah Louise, Dean Simmons College, Boston
Bedinger, Mr. George R 26 Bennet St., Boston
Beard, Miss Mary r>61 Mass. Ave., Boston
Bo-rden, Mr. Richard P 57 N. Main St., Tall River
Bowditch, Dr. Henry 1 416 Marlboro St., Boston
Brackett, Mr. Jeffrey R 41 Marlboro St., Boston
Cabot, Dr. Richard C 190 Marlboro St., Boston
Carstens, Mr. C. C 43 Mt. Vernon St., Boston
Codman, Mrs. EJ. A 227 Beacon St., Boston
Committee on Infant Social Service
of the Women's Municipal League
of Boston (Affil.) 49 Beacon St., Boston
Cody, Dr. Bdmond P New Bedford
Curry, Dr. Edmund L 299 Hanover St., Fall River
Davis, Mr. Michael M., Jr 25 Bennet St., Boston
Davis, Dr. Wm. H 23 Beaumont St., Dorchester
DeNormandie, Dr. Robert L 357 Marlboro St., Boston
Dunn, Dr. Charles Hunter 220 Marlboro St., Boston
Duvally, Mr. Nicholas P Tuft Medical School, Boston
Egan, Miss Sarah A 54 Devonshire St., Boston
Emmons, Dr. Arthur B., 2nd 86 Bay State Road, Boston
Eustis, Mrs, L. C Canton Ave., Readville
Forbes, Miss Olive N 3 Chandler St., Lexington
Foster, Mr. Warren Dunham The Youth's Companion, Boston
Farrington, Miss Elinor 5$ Bellevue St., West Roxbury
Friedman, Dr. Leo Victor 425 Marlborough St., Boston
Gallivan, Dr. Wm. J Health Department, Boston
Greenwood, Mr. Arthur W Marblehead
Greene, Mr. Henry Copley 3 Park St., Boston
Howard, Dr. Arthur A 416 Marlborough St., Boston
Huntington, Dr. James Lincoln 8 Gloucester St., Boston
Learned, Dr. Wm. T Fall River
MacCarthy, Dr. Francis H 19 Joy St., Boston
Marshall, Mr. James Fall River
Marvell, Dr. Mary W 242 Highland Ave , Fall River
Mason, Mrs. Charles E Readville
Massachusetts Babies' Hospital ( Affil. ). 43 Hawkins St., Boston
Massachusetts Milk Consumers' Asso-
ciation (Ami.) 49 Beacon St., Boston
Maverick Dispensary (Affil.) is Chelsea St., East Boston
Maynard, Mr. Harlan J 200 Summer St., Boston
Milk and Baby Hygiene Association
(Affil.) 26 Bennet St., Boston
Morse, Dr. John Lovett TO Bay State Road, Boston
Newell, Dr. Franklin S 443 Beacon St., Boston
Parsons, Miss Sara H Massachusetts General Hospital, Boston
Putnam Dr. Charles P 03 Marlboro St., Bosto-n
Putnam, Mrs. Wm. Lowell 49 Beacon St., Boston
Rotch, Dr. Thomas Morgan 197 Commonwealth Ave., Boston
Sanf ord, Miss Kate I Taunton
Sherwood, Miss Margaret P Wellesley College, Wellesley
Shackford, Miss Martha H Wellesley College, Wellesley
Smith, Dr. Richard M H29 Beacon St., Boston
Society for Helping Destitute Mothers
and Infants (Ami.) 01 Mt. Vernon St., Boston
tfweney, Mr. George W 221 Columbus Ave., Boston
Talbot, Dr. Fritz B ;;il Beacon St., Boston
Yoamg-Slaughter, Dr. Emma E 100 Wcstford St., Lowell
Michigan
Alumni Association of the Battle
Creek Sanitarium and Hospital
Training School for Nurses (Ami.) . .Battle Creek
Babies' Milk Fund Association (Affll.)..924 Brush St., Detroit
Harbour, Mrs. W- T S85 Jefferson Ave., Detroit
MEMBERSHIP LIST 429
Bowen, Mr. Lem W Detroit
Butzel, Mr. Fred 1012 Union Trust Building, Detroit
Charity Organization Society (Affil.).., 23 Library St., Grand Rapids
Clinic for Infant Feeding of the D.
A. Blodgett Home (Affil.) Grand Rapids
Cooley, Dr. Thomas B 602 Fine Arts Building, Detroit
CO'Wie, Dr. D. Murray University of Michigan, Ann Arbor
Curtis, Dr. Henry S Olivet
Douglas, Dr. Charles 959 Jefferson Ave., Detroit
Duffield, Dr. Francis 248 Seminole Ave., Detroit
Farrand Training School Alumnse As-
sociation (Affil.) Harper Hospital, Detroit
Ford, Miss Stella D 1130 Woodward Ave., Detroit
Holmes, Dr. Arthur D 270 Woodward Ave., Detroit
Inglis, Mr. James 626 Bast Gd. Blvd., Detroit
Jennings, Dr. Charles G 435 Jefferson Ave., Detroit
Johnston, Dr. Collins H 526-8 Metz Building, Grand Rapids
Joy, Mrs. H. B Fairacres, Grosse Pointe Farms
Kellogg, Dr. J. H., Supt Battle Creek Sanitarium, Battle Creek
La Forge, Miss Zoe 924' Brush St., Detroit
McGregor, Mrs. Tracy 239 Brush St., Detroit
Miner, Dr. J. B 400 S. Saginaw St., Flint
Nichols, Mrs. J. Brooks Detroit
Parker, Mrs. Walter R 285 Seminole Ave., Detroit
Peterson, Dr. Reuben University of Michigan, Ann Arbor
Phelps, Miss Jessie 16 N. Summit St., Ypsilanti
Pope, Mrs. G. D 212 Iroquois Ave., Detroit
Pope, Mrs. Willard 37 Putnam Ave., Detroit
Rosenberger, Mrs. Oscar 134 Lathrop Ave., Detroit
Race Betterment Conference (Ami.) Battle Creek
Rowland, Dr. R. S 512 Washington Arcade, Detroit
Sinclair, Miss Helen The Upper Peninsula Hospital for the
Insane, Newberry
Smith, Dr. Richard R Metz Building, Grand Rapids
Stevens, Mr. Henry Glover 615 Stevens Building, Detroit
Sutherland, Miss Anna, Supt Blodgett Home for Children, Grand
Rapids
Visiting Nurse Association (Affil.) 924 Brush St., Detroit
Minnesota
Adair, Dr. Fred. L Donaldson Building, Minneapolis
Barber, Mrs. Harry 2015 Pleasant Ave., South Minneapolis
Bracken, Dr. H. M., Secretary 'State Board of Health, Capitol Building,
St. Paul
Chesley, Dr. A. J., Director Division of Epidemiology, State Board
, of Health, Minneapolis
Christison, Dr. J. T Lowry Building, St. Paul
Crosby, Miss Caroline M 1616 Washington Ave., N., Minneapolis
Doerr, Mrs. George V 2611 Euclid Ave., Minneapolis
Douglas, Mrs. George P 2424 Park Ave., Minneapolis
Hoag, Dr. Ernest B 442 Summit Ave., St. Paul
Huenekens Dr. B. J 1037 Andrus Building, Minneapolis
Infant Welfare Department, Duluth
Scottish Rite Masons (Anil.) Masonic Temple, Duluth
Infant Welfare Society of Minneapolis
(Affil.) 820 Donaldson Building, Minneapolis
Ireys, Mrs. Charles G 401 Groveland Ave., Minneapolis
Knoblauch, Mrs. Florence W 1717 James Ave., S. Minneapolis
Lowry, Mrs. Horace 2 Groveland Terrace, Minneapolis
Mabey, Miss Nelly E % Minneapolis Tribune, Minneapolis
Ramsey, Dr. Walter R Lowry Annex, St. Paul
Rowe Dr. Olin Wallace Fidelity Building, Duluth
Ross, Mrs. Charles Frederic 4741 Fremont Ave., S., Minneapolis
Schultz, Dr. Frederic W 820 Donaldson Building, Minneapolis
Sedgwick, Dr. J. P New Syndicate Building, Minneapolis
Shevlin, Mrs. Thomas L 2205 Park Ave., Minneapolis
Sommers, Mrs. H. S 956 Portland Ave., St. Paul
Walker, Mrs. Archie Dean 419 Groveland Ave., Minneapolis
Williams, Mrs. Charles 2215 Pillsbury Ave., Minneeapolis
Woodworth, Dr Elizabeth A 3201 Clinton Ave., Minneapolis
430 MEMBERSHIP LIST
Foster Dr K Heath ............ Citizens' National Bank Bldg., Meridian
Watkins, Dr. F. L .................. Jackson
Missouri
Bleyer, Dr. A. S ..................... 516 Delmar Building, St. Louis
Brady, Dr. Jules M .................. 1367 Union Ave., St. Louis
Darling, Miss Lottie A .............. 611 N. Jefferson St., St. Louis
DeLamater, Dr. Hasbrouck, Assistant
Health Commissioner ............ Kansas City
Greene, Mrs. Charles W ............... 814 Virginia Ave., Columbia
Halbert, Mr. L. A ................... Water Works Building, Kansas City
Missouri State Nurses' Association
(Affil.) ........................... 5896 Delmar Blvd., St. Louis
Moore, Miss Elizabeth ................ 31*25 Lafayette Ave., St. Louis
Mosher, Dr. George Clark ......... 605 Bryant Building, Kansas City
Neff, Dr. Frank C. ................... 90 Rialto Building, Kansas City
St. Louis Children's Hospital (Affil.).. 6 Westmoreland Place, St. Louis
St. Louis Pure Milk Commission (Affil.) 1726 N. 13th St., St. Louis
Saunders, Dr. Edward W ............ 1601 S. Grand Ave., St. Louis
Schorer, Dr. Edwin H ................ 1010 Rialto Building, Kansas City
Stanley, Miss Louise ................. 1215 Hudson Ave., Columbia
Tuttle Dr. George M ............... 4917 Maryland Ave., St. Louis
Veeder, Dr. Borden S ................. 1806 Locust St., St. Louis
Volker, Mr. Wm ................. , ... 308 W. 8th St., Kansas City
Wilhelm, Dr. F. E ................. 719 Gloyd Building, Kansas City
Zahorsky, Dr. John ................ 1460 S. Grand Ave., St. Louis
Montana
Dean, Dr. Maria M ................. Helena
Nebraska.
Lynch, Dr. Delia A .............. 1002 W. O. W. Building, Omaha
McClanahan, Dr. H. M ............ 468 Brandeis Building, Omaha
Nebraska State Association of Grad-
uate Nurses (Affil.) ............... Omaha
New Hampshire
Bennett, Dr. H. W. N ............... Manchester
Infant Aid Association (Affil.) ........ Manchester
Streeter, Mrs. Frank S ............. 234 N. Main St., Concord
The Berlin Mills Company's District
Nurse (AffiL) ...................... Berlin
New Jersey
Alexander, Mrs. A .................. '..Castle Point, Hoboken
Babies' Hospital (Affil.) ............. 437 High St., Newark
Babies' Hospital Milk Dispensary
(Affil.) .......................... 437 High St., Newark
Bain, Miss ........................ ,% Board of Health, Montclalr
Burasted, Dr. C. V. R ................. 235 Grafton Ave., Newark
Coit, Dr. Henry L .................... 277 Mt, Prospect Ave., Newark
Colgate, Mrs. Sidney M .............. 363 Center St., Orange
Dennis, Dr. L ....................... 49 Ridge St., Orange
Diet Kitchen of the Oranges (Aral.) .. .224 Essex Ave., Orango
Folsom, Miss Eleanor ................ Llewellyn Park, Orange
Francisco, Mr. Stephen, President.. .-Fairfield Dairy Co., Montclalr
Harvey, Dr, Thomas W., Jr ............ 4C3 Main St./ Orange
Hoffman, Mr. Frederick L ............. Prudential Insurance Co., Newark
Hogan, Mr. Edward P ................. 7 Second St., Weehawken
Howell, Mrs. J. W ................... till Ballantine Parkway, Newark
Levy, Dr. Julius ..................... 101 Littleton Ave., Newark
MacNutt, Dr. J. Scott ............... r~>27 Main St., Orange
Marvel, Dr. Philip ................... 1016 Pacific Ave., Atlantic City
MEMBERSHIP LIST 431
Moore, Mrs. Paul 78 Madison Ave., Mornstown
Musselman, Miss Nellie S 105 S. Little Rock Ave., Ventnor
Nicholson, Mrs. Wm. H., Jr 327 S. Second St., Millville
Pinneo, Dr. Frank W 199 Garside St., Newark
Roebling, Mrs. Karl G 211 W. State St., Trenton
Stern, Dr. Arthur 224 B. Jersey St., Elizabeth
Stewart, Dr. W. Blair Cor. North Carolina and Pacific Aves.,
Atlantic City
Synnott, Dr. J. Martin 34 S. Pullerton Ave., Montclair
Van Winkle, Mrs. Abram 35 Lincoln Park, Newark
Visiting Nurse Association (Affil.) . . . .122 Magnolia Ave., Elizabeth
New York
Armstrong, Dr. Donald B 105 E. 22nd St., New York City
Babbitt, Miss Ellen C New York City
Babies' Dairy Association (Affll.) . ..8 W. 49th St., New York City
Babies' Hospital (Affil.) 135 E. 55th St., New York City
Babies' Milk Dispensary of Buffalo
(Affil.) 181 Franklin St., Buffalo
Baby Welfare Committee of Utica
(Affil.) 240 Genesee St., Utica
Baker, Dr. S. Josephine, Chief Division of Child Hygiene, Department
of Health, New York City
Benson, Dr. Reuel A 8 W. 49th St., New York City
Biggs, Dr. Herman M 113 W. 57th St., New York City
Bock, Dr. Franklin Wm 133 Clinton Ave., S., Rochester
Brewster, Mr. George S 51 Wall St., New York City
Brooklyn Bureau of Charities District
Nursing Committee (Ami.) 80 Schermerhorn St., Brooklyn
Brooklyn Children's Aid Society (Affil.) .72 Schermerhorn St., Brooklyn
Brown, Dr. W. M 272 Alexander St., Rochester
Bruere, Mr. Robert W 206 V 2 W. 13th St., New York City
Bureau of Health (Affil.) Rochester
Bureau of Municipal Research (Affil.) . .261 Broadway, New York City
Button, Dr. Lucius L 265 Alexander St., Rochester
Calvert, Mrs. John B 201 W. 57th St , New York City
Camp Fire Girls of America (Affil.) 118 E. 28th St., New York City
Clark, Miss Mary Vida 105 E. 22nd St,, New York City
Clarke, Dr. T. Wood 240 Genesee St., Utica
Committee on Prevention of Blindness
of th'e New York Association for
the Blind (Affil.) 105 E. 22nd St., New York City
Courtney, Bishop F Madison Ave. and 75th St., New York
Darlington, Dr. Thomas 30 Church St., New York City
Department of Home Economics N. Y.
State College of Agriculture (Affil.) . .Ithaca
Domser, Dr. Benjamin M Cor. Pond and Lodi Sts., Syracuse
Dunham, Mrs. Edward K 35 E. 68th St., New York City
Erlanger, Mr. A <>5 Worth St., New York City
Faust, Dr. Louis 19 Jay St., Schenectady
Faust, Dr. Wm. P 22 Jay St., Schenectady
Flagler, Mrs. Harry H 32 Park Ave., New York City
Folks, kr. Homer 105 E. 22nd St., New York City
Fox, Mr. Henry J.. . , 150 W. 86th St., New York City
Fox, Mr. Mortimer J., Jr 150 W. 86th St, New York City
Fox, Mr. Hugh F New York City
Frankel, Dr. Lee K 1 Madison Ave., New York City
Freeman, Dr. Rowland G 211 W. 57th St., New York City
Fronczak, Dr. Francis 13. , Health
Commissioner Municipal Building, Buffalo
Frost, Dr. Conway A 8 Plant St., Utica
Goler, Dr. George W., Health Officer ... Rochester
Goodrich, Miss Annie W N. Y. State Department of Education,
Albany
Guilf oy, Dr. Wm. H Department of Health, New York City
Harkncss, Mr. Edward L 26 Broadway, New York City
Hart, Dr, Hastings H 130 B. 22nd St., New York City
Hatch, Mr. Edward, Jr c /oLord & Taylor, New York City
Haynes, Dr. Royal Storrs 375 West End Ave., New York City
Hebrew Infant Asylum (1914) (Affll.) . .Kingsbridge Road, New York City
I-Mman Dr. Henry 30 W. 88th St., New York City
Hess, Dr. Alfred F 10 W. 86th St., New York City
432 MEMBERSHIP LIST
Hiegins, Mr. Charles M 101 9th Ave., Brooklyn
Hill, Mr. Nicholas S., Jr 100 William St., New York City
Hilton, Mrs. George Porter 240 State St., Albany
Holden, Mrs. Edwin B 323 Riverside Drive, New York City
Holt, Dr. L. E'mmett T4 W. 55th Street, New York City
Homer, Madame Louise 4S E. 78th St., New York City
Hoopes, Mr. Maurice Glens Falls
Infant Felfare Committee of Associa-
ted Churches and Charities ( Anil. ).. 508 Bast Genesee St., Syracuse
Ives, Mrs. Henrietta Bellevue and Allied Hospitals Social
Service Department, New York City
Jacobi, Dr. Abraham 19 E. 47th St., New York City
Johnson, Mrs. Surges Port Washington, Nassau Co.
Kellogg, Mrs. F. Leonard 118 E. 70th St., New York City
Kerley, Dr. Charles' G 132 W. Slst St., New York City
Kosmak, Dr. George 307 Second Ave., New York City
Le Fetra, Dr. Linnaeus E 113 E. 61st St., New York City
McKechnie, Miss Mary W 420 W. 118th St., New York City
Macy, Dr. Mary Sutton jLOl W. 80th St., New York City
Main, Mr. William 100 Broadway, New York City
Mason, Miss Mary R 105 E. 22nd St., New York City
Metropolitan Life Insurance Co. In-
dustriaj Department (Affil.) New York City
Mills, Mr. Wm. Wirt 249 Manor Road, West New Brighton
Mosher, Mr. H. T 216 Alexander St., Rochester
New York Diet Kitchen Association
(Affil.) 1 W. 34th St., New York City
New York Milk Committee (Affll.) 105 E, 22nd St., New York City
New York State Nurses' Association
(Affil.) 419 W. 144th St., New York City
North, Dr. Charles E 30 Church St., New York City
Nutting, Miss M. Adelaide Teachers' College, Columbia University,
, New York City
Olcott, Mr. Dudley Albany
Olcott, Mrs. E. E 38 W- 39th St., New York City
Page, Dr. Agnes E gj>9 State St., Albany
Palmer, Dr. Joseph C 5 5 E. Fayette St., Syracuse
Parsons, Miss Marion G 51 W. 122nd St., New York City
Perkins, Miss Emily S Riverdale-on-Hudson
Phelps, Mr. Edward Bunnell 500 W. 122nd Street, Now York City
Pisek, Dr. Godfrey R 36 E. 62nd St., New York City
Potter, Dr. Philip S 742 S. Beach St., Syracuse
Pratt, Mrs. Charles M Seamoor, Glen Cove, Long Island
Rambo, Dr. Wm. S 43 N. Plymouth Ave., Rochester
Robinson, Mrs. Theodore Douglas Mahaque Farm, Mohawk, Hcrkimcr Co.
Roosevelt, Mrs. Franklin H 49 E. 65th St., New York City
Rosenbaum, Mr. S. G 207 W. 24th St., New York City
Russell, Dr. N. G 469 Franklin St., Buffalo
Russell, Miss Martha M 447 W. 59th St., New York City
Sage, Mrs, Isabel W Menando Road, Albany
Saint Margaret's House and Hospital
(Affil.) Albany
Sands, Dr. Georgiana Port Chester
Schiff, Mr. Jacob H Kuhn, Loeb & Co., New York City
Schneider, Mr. Franz, Jr 31 Union Square, New York City
Schwarz, Dr. Herman 50 E. 91st St, New York City
Seward, Mr. W. R 218 Alexander St, Rochester
Shaw, Dr. Henry L. K 361 State St, Albany
Simon, Mrs. R. E 320 W. 87th St., New York City
Southworth, Dr. Thomas S 807 Madison Ave., New York City
Straus, Mr. Nathan 27 W. 72nd St., New York City
Strauss, Mr. Frederick % J. V. W. Seligman & Co., New York
City
Sub-Committee on Assisting and Pro- 105 E. 22nd St., New York City
viding Situations for Mothers and
Infants of tbe New York State
Charities Aid Association (Affil.)
Taller, Mrs. T. Suffern 21 W. Slst St, New York City
The American Nurses' Association
(Affil.) 410 W. 144th St., Now York City
Thacher, Mrs. Archibald 4U E. Slst St, New York City
The National League of Nursing
Education (Affil.) 420 W. 118th St., New York City
MEMBERSHIP LIST 433
Tiemann, Miss Edith Winifred 67 Midwood St., Brooklyn
vander Bogert, Dr. Frank Ill Union St., Schenectady
Van Ingen, Dr. Philip 125 E. 71st St., New York City
Wakeman, Mr. Arthur E 72 Schermerhorn St., Brooklyn
Weston, Miss Alice B 105 E. 22nd St., New York City
White, Mr. Thomas R., Jr 100 Broadway, New York City
Wile, Dr. Ira S 230 W. 97th St., New York City
Willcox, Prof. Walter F Cornell University, Ithaca
Winslow, Prof. C.-E. A College of the City of New York
Winters, Dr. Joseph E 25 W. 37th St., New York City
Wood, Dr. Thomas D Columbia University, New York City
Wright, Mr. J. H 55 Plymouth Ave., Rochester
Wynkoop, Dr. B. J 401 James St., Syracuse
North. Carolina
Paquin, Dr. Paul Asheville
State Board of Health (Affil.) Raleigh
Weil, Mrs. Mina Goldsboro, Wayne Co.
North Dakota
McCannell, Dr. A. J 1145 S. Main St., Minot
Ohio
Abbott, Mr. Gardner T 1215 Williamson Building, Cleveland
Alcott, Mrs. C. B Stillman Road, Cleveland
Auer, Mrs. C. W 1309 W. 112th St., Cleveland
Babies' Dispensary and Hospital of
Cleveland (Affil.) 2500 E. 35th St., Cleveland
Baehr, Mr. Herman 8309 Detroit St., Cleveland
Baldwin, Mr. and Mrs. Arthur D Lake Shore Boulevard, Cleveland
Bill, Dr. Arthur 2082 E. 96th St., Cleveland
Blair, Dr. B. H Lebanon
Brokaw, Dr. Wm. L 2102 E. 55th St., Cleveland
Brown, Miss Elizabeth L v 2727 Euclid Ave., Cleveland
Brown, Mr. Alexander C 1974 B. 71st St., Cleveland
Bruner, Dr. Wm. E 13380 Euclid Ave., Cleveland
Bureau of Municipal Research (Affil.).. 602 Schwind Building, Dayton
Calfee, Mr. R. M 1608 Williamson Building, Cleveland
Cameron, Mr. L. J Central National Bank, Cleveland
Chisholm f Mrs. Wm 3618 Euclid Ave., Cleveland
Clark, Mrs. Harold F 1899 E. 82nd St., Cleveland
Cleveland Day Nursery and Free Kin-
dergarten Association (Affil.) 1851 E. 82nd St., Cleveland
Conrad, Mr. A. J 10127 South Boulevard, Cleveland
Crile, Dr. George 6203 Euclid Ave., Cleveland
Cummer, Miss R. H 1950 E. 79th St., Cleveland
Cushing, Mrs. Melanie II 4712 Euclid Ave., Cleveland
Gushing, Mrs. Wm 2908 Euclid Ave., Cleveland
Cutler, Prof. J. E 11311 Hessler Road, Cleveland
Day, Mrs. B. L Akron
Derereux. Mrs. M. F 2525 Euclid Ave., Cleveland
Bngel, Mrs. Austa W 1720 E. 116th Place, Cleveland
Feiss, Mrs. Paul L 11452 Euclid Ave., Cleveland
Flory, Mrs. W. L. 9906 Lament Ave., Cleveland
Ford, Dr. C. E., Secretary Board of Health, Cleveland
Furrer, Dr. Arnold F 1110 Euclid Ave., Cleveland
Gait, Mrs Wm.. Glendale, Cincinnati
Garfield, Mr. and Mrs. Abram Lake Shore Boulevard, Cleveland
Garfield, Mrs. James R 3328 Euclid Ave., Cleveland
Gerstenberger, Dr. H. J 2500 E. 35th St., Cleveland
Gitchell, Miss Katherine Akron
Glass, Dr. G. L 13491 Euclid Ave., Cleveland
Goodhue, Dr. George Dayton
Grandin, Mr. and Mrs. G. W Magnolia Drive, Cleveland
Greene, Mr. and Mrs. Edward B 10831 Magnolia Drive, Cleveland
Hamann, Dr. C. A 416 Osborn Building, Cleveland
Hanna, Mrs. Howard M., Jr Station H, Cleveland
Hanna, Mr. and Mrs. H. M 2417 Prospect Ave., Cleveland
Hanna, Mrs. Mark, 2nd Station H, Cleveland
Hart, Mr. Louis F 1875 E. 89th St., Cleveland
Harvey, Mr. M. C 215 Cuyahoga Building, Cleveland
434 MEMBERSHIP LIST
" Harvey, Mr. P. W 4608 Euclid Ave., Cleveland
Hencke, Mr. J. W 2216 E. SOth St , Cleveland
Herrick, Mrs. F. C 11318 Euclid Ave., Cleveland
Hogen, Mr. F. G 1823 E. 97th St., Cleveland
Holden, Mrs. L. Deane Station H, Cleveland
Hoover, Dr. C. F 702 Rose Building, Cleveland
Hopkins, Mr. Arthur T 13921 Euclid Ave , Cleveland
Hord, Mrs. John Cleveland
Howell, Dr. J. Morton Reibold Building, Dayton
Instructive District Nursing Associa-
tion ( Affil.) 276 E. State St., Columbus
Ireland, Mrs. Robert L, Lake Shore Boulevard, Cleveland
Johnson, Miss M. L 1654 E. 86th St., Cleveland
Ladd, Dr. L. W 211 Osborn Building, Cleveland
Lamb, Dr. Frank H 940 E. McMillan St., Cincinnati
Leete, Miss Harriet H 2500 E'. 35th St., Cleveland
Light, Dr. A. L 1000-1001 U. B. Building, Dayton
Lowman, Dr. John H 1807 Prospect Ave., S. E., Cleveland
McMillin, Mrs. S. S Station H, Cleveland
Marks, Mr. Martin A 5932 Broadway, Cleveland
Mather Mrs. A. S 2605 Euclid Ave., Cleveland
Mather, Mr. Samuel Western Reserve Building, Cleveland
Meckes, Mr. Gus 1327 W. 9th St., Cleveland
Metcalf, Dr. Maynard M Oberlin College, Oberlin
Miller, Mrs. Elizabeth C. T 3738 Euclid Ave., Cleveland
Miller, Dr. T. Clarke Massillon
Morgan, Miss Edith S 2500 E. 35th St., Cleveland
Morgan, Mrs. C. J 2142 Euclid Ave , Cleveland
Morgenroth, Dr. S 202 Everett Building, Akron
Morse, Mrs. J. C Station H, Cleveland
Newell, Mrs. J. E Mentor
Ohio State Association of Graduate
Nurses (Affil.) Massillon
Otis, Mr. Charles A Cuyahoga Building, Cleveland
Otis, Mrs. Harrison G 9616 Euclid Ave., Cleveland
Patterson, Dr. C. L Dayton
Perkins, Mr. Douglas 1404 W. 3rd St., Cleveland
Peskiud, Dr. A 2414 E, 55th St., Cleveland
Phillips, Dr. John 10509 Euclid Ave., Cleveland
Pope, Dr. Carlyle 1950 E. 81st St., Cleveland
Prescott, Mrs. O. W, . , 1813 E. 65th St., Cleveland
Rachford, Dr. B. K 323 Broadway, Cincinnati
Rees. Mrs. William 3624 Euclid Ave., Cleveland
Rigelbaupt, Dr. Wm 2346 E. 43rd St., Cleveland
Rosenfeld, Miss Irma L 1706 Magnolia Drive, Cleveland
Ruh, Dr. H. O 2500 E. 35th St., Cleveland
Saeger, Mr. Wilford C Hippodrome Building, Cleveland
Samuel, Miss Mary A., R. N The Lakeside Hospital, Cleveland
Schmidlapp, Mr. J. G Cincinnati
Scott Dr. N. Stone M3 Citizens' Building, Cleveland
Selby, Dr. C. D 234-235 Spitzer Building, Toledo
Sellenings, Dr. O. H 816 Oak St., Columbus
Shackleton, Dr. W. E 503 Osborn Building, Cleveland
Sherwin, Miss Belle 3328 Euclid Ave., Cleveland
Sheridan, Mrs. R. B 1893 M. 82nd St, Cleveland
Sherwin, Mrs. John Overlook Road, Euclid Heights, Cleve-
land
Sherwin, Miss Prudence Willoughby
Silver, Mrs. M. T 1725 Magnolia Drive, Cleveland
Skeel, Dr. A. J 1834 E. 65th St, Slerelanfl
Stevenson, Dr. Mark D 165 B. Market St., Akron
Stokes, Mrs. Ada S 220 W. 7th Ave., Cincinnati
Strong, Mrs. Ann Gilchrist, Director . . . Cincinnati Kindergarten Training
School, Linton St., Cincinnati
Sullivan, Miss Selma 7218 Euclid Ave., Cleveland
Taylor, Dr. Ralph B 1275 N. High St., ColurabuB
Thomas, Dr. J. J 1110 Euclid Ave., Cleveland
Titlow, Dr. Bennetta D 351 Limestone St., Springfield
Todd, Dr. Harvey D 38 Brown Building, Akron
Tuttle, Miss Jennie L 276 E. State St., Columbus
Tyler, Mrs. W. S 1415 Kuclld Ave., Cleveland
Visiting Nurse Association (Affil.) - . . .220 W. Seventh Ave., Cincinnati
Visiting Nurse Association (Affil.) 612 St. Clair Ave., Cleveland
MEMBERSHIP LIST 435
Wade, Mr. and Mrs. Jeptha H 3903 Euclid Ave., Cleveland
Waite, Dr. F. C 1778 Crawford Road, Cleveland
Wason, Mrs. Charles W 9209 Euclid Ave., Cleveland
White, Mrs. W. T Station H, Cleveland
Whitlock, Mr. and Mrs. E. H Lake Ave., Cleveland
Williams, Mr. Edward M 10916 Magnolia Drive, Cleveland
Witter, Dr. C. Orville 1838 W. 57th St., Cleveland
Wolfenstein, Dr. S 1725 E. 115th St., Cleveland
Woodford, Mr. W. R 2692 Berkshire Road, Cleveland
Wright, Mr. Howell 501 St. Glair Ave., Cleveland
Wyckoff, Dr. C. W 2500 E. 35th St., Cleveland
Oregon
Bilderback, Dr. J. B 903 Corhett Building, Portland
Calvin, Mrs. Henrietta W Corvallis, Oregon Agricultural College
Cardwell, Dr. Mae H 601, The Dekum, Portland
Hall, Dr. Robert G 907 Journal Building, Portland
Moore, Mr. H. H Portland
Pennsylvania
Anders, Dr. J. M 1605 Walnut St., Philadelphia
Atlee, Mrs. John L 29 E. Orange St., Lancaster
Batt, Dr. Wilmer R., Resistrar of
Vital Statistics Department of Health, Harrisburg
Bausch, Dr. F. R 109 N. Second St., Allentown
Bok, Mrs. Edward Merion
Brunner, Dr. Henry G 542 N. llth St., Philadelphia
Burns, Dr. H. B Nixon Building, Pittsburgh
Burr, Dr. Charles W 1918 Spruce St , Philadelphia
Carpenter, Dr. Howard Childs 1805 Spruce St., Philadelphia
Cheston, Dr. Radcliffe Chestnut Hill, Philadelphia
The Child Federation (Affll.) Real Estate Trust Building, Philadelphia
Coles, Dr. Strieker 2103 Walnut St., Philadelphia
Children's Aid Society of Pennsyl-
vania (Affll.) 421 S. 15th St., Philadelphia
Craig, Dr. Frank A 732 Pine St., Philadelphia
Davis, Mr. H. B 6433 Monitor St., Pittsburgh
DIxon, Dr. Samuel G State Commissioner of Health, Harris-
burg
Eaton, Dr. Percival J 715 N. Highland Ave., E. E., Pittsburgh
Edwards, Dr. J. F r 431 Sixth Ave., Pittsburgh
Edwards, Dr. Ogden M., Jr 5607 Fifth Ave., Pittsburgh
Elliott, Dr. John D 1421 Spruce St., Philadelphia
Elterich, Dr. Theodore J 724 Highland Building, Pittsburgh
Fife, Dr. Charles A 2033 Locust St., Philadelphia
Flick, Dr. Lawrence F 738 Pine St., Philadelphia
Fox, Miss Rena P., R. N Babies' Hospital of Philadelphia, Bryn
Mawr and Parkside Aves., Wynnfield
Gucker, Mr. F. T Witherspoon Building, Philadelphia
Hamlll, Dr. S. McC 1822 Spruce St., Philadelphia
Hill, Dr. Howard Kennedy 339 S. 18th St., Philadelphia
Jenkins, Mrs. Charles F 150 W. Washington Lane, Germantown
Jenks, Dr. Horace H Wayne
Johnson, Mr. Roswell H University of Pittsburgh, Pittsburgh
Johnson, Dr. W. N 8460 Germantown Ave., Philadelphia
Hammond, Dr. Frank C 3338 N. Broad St., Philadelphia
Jones, Dr. Eleanor C 1531 N. 15th St., Philadelphia
Jump, Dr. Henry D 4634 Chester Ave., Philadelphia
Keen, Miss Dora 1729 Chestnut St., Philadelphia
Lea, Mrs. Langdon Bala
Leconte, Dr. Robert G 1530 Locust St., Philadelphia
Levy, Rabbi J. Leonard "Seven Gables," Schenley Park, Pitts-
burgh
Lewis, Dr. Bertha Box No. 23, Bryn Mawr
Litchfleld, Dr. Lawrence .;j431 Fifth Ave., Pittsburgh
Madeira, Miss Edith 320 Walnut St, Philadelphia
Martin, Dr. Edward 1506 Locust St, Philadelphia
Mellon, Mr. A. W 5052 Forbes St., Pittsburgh
Mercur, Dr, Wm. H Fifth Ave and St. James St., Pittsburgh
Metcalf, Miss C. Margaret 205 W. 9th St., Erie
Miller, Dr. Harold A Pittsburgh Life Building, Pittsburgh
436 MEMBERSHIP LIST
Miner, Dr. Charles H 115 S. Franklin St., Wilkes-Barre
Monges, Dr. Willis L Jefferson Medical College, Philadelphia
Mubrenan, Dr. John P 1228 S. Broad St., Philadelphia
Neff, Dr. Joseph S.. Director Department of Public Health and -Chari-
ties, Philadelphia
Newlin, Dr. Arthur 1804 Pine St., Philadelphia
Newmayer, Dr. S. W 1834 Girard Ave., Philadelphia
Peck, Dr. Elizabeth L 4113 Walnut St., Philadelphia
Perkins, Miss Charlotte 1029 Spruce St., Philadelphia
Piersol, Dr. George Morris 1927 Chestnut St., Philadelphia
Posey, Dr. Louis P 1807 Walnut St., Philadelphia
Preston. Mrs. Frances Metcalf 205 W. 9th St., Brie
Price, Dr. Harry T Westinghouse Building, Pittsburgh
Reckefus, Dr. Charles H., Jr 506 N. 6th St., Philadelphia
Robinson, Mrs. Louis N Swarthmore
Royer, Dr. B. Franklin Department of Health, Harrisburg
Schamberg, Dr. Jay F 1922 Spruce St., Philadelphia
Simmons, Dr. Richard H Shamokin
Sinclair, Dr. John F 4103 Walnut St., Philadelphia
Sprague, Dr. Frances R Pembroke Road, Bryn Mawr
Stahl, Dr. B. Franklin ..1727 Pine St., Philadelphia
Stahr, Dr. Charles P 17 B. Walnut St., Lancaster
Starr, Dr. Louis 1818 Rittenhouse Square, Philadelphia
Stotesbury, Mrs. Edward 1925 Walnut St., Philadelphia
Sykes, Dr. Henry Philadelphia General Hospital, Phila.
Tallant, Dr. Alice Weld 1807 Spruce St., Philadelphia
Taylor, Dr. Marianna St. Davids
Van Kirk, Miss Anne D 5414 Ellsworth Ave., Pittsburgh
Visiting Nurse Association (Affil.) York
Wadhams, Dr. Raymond L 72 N. Franklin St., Wilkes-Barre
Walsh, Dr. Joseph 736 Pine St., Philadelphia
Waterman, Mr. Richard L 316 Walnut St., Philadelphia
Weber, Dr. S. B Lancaster
Whiton, Miss Lydia A City Hospital, Meadville
Williams, Mr. Ellis D 560 Drexel Building, Philadelphia
Wright, Dr. J. W Health Officer, Erie
Ziegler, Dr. Charles Edward Forbes and Halket Sts , Pittsburgh
Rhode Island
Burnett, Dr. H. W 120 Waterman St., Providence
Chapin, Dr. Charles V Superintendent of Health, Providence
Packard, Dr. Mary S Arnold Mills
Providence District Nursing Associa-
tion (Affll.) 109 Washington St., Providence
Putnam, Dr. Helen C Rhode Island Ave., Providence
Public Library (Affll.) Providence
Stone, Dr. Ellen A 280 Waterman St., Providence
Swarts, Dr. Gardner T.. Secretary State Board of Health, Providence
Thacher, Miss Eunice B Westerly, Watch Hill
South Carolina
Geer, Dr. Charles C 410 University Ridge, Greenville
Jordan, Dr. Fletcher Bank of Commerce Building, Greenville
South. Dakota
Tough, Miss Mary Brookings
Tennessee
Crockett, Mrs. S. S 710 Belmont Ave., S., Nashville
Hibbett, Dr. W. BJ City Hall, Nashville
Wilson, Dr. Owen H 1620 West End Ave., Nashville
JU.JUMJtJJjJlitoJa.ir JjJLHT
Texa
Andrews, Mrs. Frank ; . . 910 Bell Ave., Houston
Decherd, Dr. George M 405 Scarbrough Building, Austin
Houston Settlement Association (Affil.). 61 Gabel St., Houston
Utah
Ladies' Literary Club of Salt Lake
City (Affll.) . . . Salt Lake City
?i eg ^ Mrs ' ' Rac ^ e L U ', 30 E. 1st Fourth St., Salt Lake City
Utah Congress of Mothers (Affll.) Salt Lake City ,
Walker, Mr. M, H % Walker Bros., Salt Lake City
Vermont
Hawley, Dr. Donly C 204 Pearl St., Burlington
Holton, Dr. Henry D., Secretary State Board of Health, Brattleboro
Virginia
Department of Health (AffiL) Richmond
Grandy, Dr. Charles R 410 Taylor Building, Norfolk
Jordan, Prof. H . E University of Virginia, Charlottesville
Macon, Dr. W. D University of Virginia, Charlottesville
Marshall, Dr. Harry I 1 University of Virginia, Charlottesville
Newton, Dr. McGuire 1010 Floyd Ave., Richmond
Old, Dr. Herbert 2GO Freemason St., Norfolk
Royster, Dr. L. T 205 Taylor Building, Norfolk
Washington
Hurn, Miss Reba J 1228 llth Ave., Spokane
Kelley, Dr. Kugene R., Secretary State Board of Health, Seattle
Pritchard, Mrs. Carl Isaac Shelton
"Went Virginia
Colwell, Miss Rachel L University of West Virginia, Morgan-
town
Wicon*in
Child Welfare Division, Health De-
partment (Affil.) City Hall, Milwaukee
Dinneen, Miss N., Supt Milwaukee Infants' Home and Hospital,
I Milwaukee
Frost, Prof. W. D University of Wisconsin, Madison
Marlatt, Prof. Abby L University of Wisconsin, Madison
Milwaukee Maternity Hospital and
Free Dispensary ABSOCiation (Ami.).- 554 Fourth St., Wilwaukee
Myers, Dr. Albert Wm *. 141 Wisconsin St., Milwaukee
Ravenel, Dr. Mazyck P University of Wisconsin, Madison
Tomklewicz, Dr. Irene G. . - , 545 Lincoln Ave., Milwaukee
Visiting Nurse Association (Affll.) Mau Claire
Visiting Nurse Association (Affil.) 024 Caswell Building, Milwaukee
CONTRIBUTORS TO SPECIAL FUNDS
Canada
MacMurchy, Dr, Helen Toronto
California
Brown, Dr. Adelaide San Francisco
Connecticut
Stanley, Mr, A. W New Britain
438 MEMBERSHIP LIST
District of Columbia
Adams, Mr. Byron S ................. Washington
Bowie, Mr. W. W .................... Washington
Garrison, Mr. Fielding H. , .......... Washington
Grinnell, Mrs, Wm. Morton ........... Washington
Heurich, Mrs. Christian .............. Washington
Janney, Mr. Bernard T ............... Washington
King, Mr. Wm. B .................... Washington
Kober, Dr. George W ................ Washington
Lincoln, Mr, Robert T .............. Washington
Muncaster, Dr. S. B ................. Washington
Shute, Mr. D. K ................... Washington
Spofford, Miss Florence P ............ Washington
Wilmer, Dr. W. H ................... Washington
Illinois
Farwell, Mrs. Fanny D ............... Lake Forest
Henderson, Prof. Charles R ........... Chicago
Kentucky
Shaver, Miss Elizabeth ............... Louisville
Maryland
Cocaran, Mr, Wm. F., Jr .............. Baltimore
Johnston, Mrs. Josiah Lee ............ Baltimore
Koppelman, Mr. Charles H ............ Baltimore
Sherwood, Dr. Mary. ................. Baltimore
Swindell, Mr. C. J. B ................. Roland Park
White, Mrs. Francis A ................ Baltimore
Williams, Dr, J. Whitridge ............ Baltimore
DeNormandie, Dr. Robert L ........... Boston
Putnam, Mrs. Wm. Lowell ........... Boston
New York:
Erlanger, Mr. A ................. New York City
Goler, Dr. George W .................. Rochester
Harkness, Mr, Edward L ............. New York City
Ohio
Babies 1 Dispensary and Hospital ...... Cleveland
Rhode Islam!
Putnam, Dr. Helen C ................. Providence
Teaca*
Andrews, Mrs. Frank ................ Houston
Virginia
Harrison, Mrs. Fairfax ............... Belvolr
INDEX
Abt, I. A., M. D, Teaching of Hy-
giene and its Relation to the
Prevention of Infant Mor-
tality, 01
Discussion, 129
Adams, Samuel S., M. D., Chairman,
General Session, 320
Address of the President, L. Em-
mett Holt, M. D., 24
Address, Sunday Session, Wm. C.
Woodward, M. D, 286
Affiliated Societies, Reports of, 367
Ahrens, Minnie H., Discussion, 71, 83
Babbitt, Ellen C., The Foundling
Asylum and the Unmarried
Mother, 363
Babies' Dispensary and Hospital,
Cleveland, 412
Babies' Dispensary Guild, Hamilton.
Ontario, 368
Babies' Hospital t
Boston, 382
Newark, N. J., 398
Babies' Milk Fund Association
Baltimore, 378
Detroit, 391
Louisville, 376
Baby Saving Activities, Discussion
of Ideal Plan:
Department of Health, C. E.
Ford, M, D., 341
Relation of Babv-Saving Activi-
ties to the Department of
Health and to Each Other, S.
Jonephine Baker, M. D,, 351
Ideal Visiting Nursing, The, M,
Adelaide Nutting, 353
Place of the Maternity Hospital,
The, J. Whitridge Williams,
M. D., 355
Place of the Hospital, The, L.
Emmett Holt, M, D., 359
Dispensary, Social Service De-
partment, The, J. H, Mason
Knox, Jr., 361
Foundling Asylum and the Un-
married Mother, The, Ellen C,
Babbitt, 363
Part of the Church, The, John
Van Schaick, D. D., 365
Baby, The Claim of the, J. H, Mason
Knox, Jr., M. D., 289
Baker, S. Josephine, M. D., Relation
of Baby-Saving Activities to
the Department of Health
and to Each Other, 351
Discussion, 71, 96, 97, 203, 207,
239, 304, 311, 351
Baltimore
Babies' Milk Fund Assn., 37S
Council Milk and Ice Fund,
377
Battle Creek Sanitarium Training
School for Nurses, 390
Bell, Miss, Associated Charities, 331
Bennett, H. W., M. D., Discussion,
205
Bibliography, 54, 126, 146, 150-156
Binzel, Alma, Discussion, 257, 272
Birmingham, Ala,, Infant Welfare
Society, 368
Birth Registration, 48, 231, 296, 311,
313, 320
Blind, Assn. for the, New York, 400
Boston :
Division of Child Hygiene, 187.
223, 226
Department of Health, Prenatal
and Postnatal Work, 223, 226
Committee on Infant Social Ser-
vice, Women's Municipal Lea-
gue, Boston, 187, 223
Maverick Dispensary, 227, 385
Milk and Baby Hygiene Asso-
ciation, 226, 235, 387
Society for Helping Destitute
Mothers and Infants, 389
439
440
INDEX
Boyd, T. Hunter, Discussion, 84
Burlington, la., Child Welfare Com-
mittee, 374
Calvin, Mrs. Henrietta, Discussion,
277
Chancellor Memorial Milk Station,
La Salle, 372
Charity Organization Society, Grand
Rapids, 392
Chicago Infant Welfare Society, 371
Lying-in Hospital and Dispen-
sary, 372
Child Federation of Philadelphia,
415
Child Hygiene
Boston, Division of, 223, 226,
387
Newark, Dept. of, 244
New York Dept. of Health,
49, 59, 239, 351
Child Welfare Committee, Burling-
ton, la., Chapter of the Red
Cross, 374
Child Welfare Service, Providence
District Nursing Assn., 417
Children's Aid
Assn. of Indianapolis, 373
Society of Pennsylvania, 416
Children's Clinic, Cincinnati, 413
Children's Dispensary and Hospital
Assn., South Bend, 374
Children's Hospital, St. Louis, 396
Christian Service League of Amer-
ica, 375
Cincinnati
Children's Clinic, 413
Visiting Nurse Assn., 413
Claim of the Baby, The, J. H.
Mason Knox, Jr., M. D., 289
Clarke, T. Wood, M. D., Discussion,
82, 97
Midwifery Report, 238
Clement, Fannie F., Infant Mortal-
ity Nursing Problems in Rural
Communities, 75
Discussion, 68, 73, 80, 81
Cleveland Babies' Dispensary and
Hospital, 412
Visiting Nurse Assn., 413
Clinic for Infant Feeding, Grand
Rapids, 392
Coit, Henry L., M. D., Report on
English Speaking Conference
on Infant Mortality, 55
Cole, Leon I., M. D., Discussion, 146
Committee on Infant Social Service,
Women's Municipal League,
Boston, 187, 223
Conferences and Congresses on In-
fant Mortality, 42, 55
Consultations for Nurslings (See
Also Baby Wei-fare Stations
and Infant Welfare Stations),
44, 45, 46
Continuation Schools of Home Mak-
ing, Helen C. Putnam, M. D.,
251
Bride's Course, Vienna, 262
Committee Report, 257
Discussion :
Jacobs, Emma Suter, 261)
Binzel, Alma, 272
Calvin, Mrs. Henrietta, 277
Lippitt, Louisa C., 278
True, A. C., Ph. D., 278
Hunt, Caroline L., 280
Marlatt, Abby L., 282
Cooley, T. B., M. D., Discussion, 128,
131
Council Milk and Ice Fund, Balti-
more,
Davenport, Chas. B., Ph. D., Results
from Experimental Breeding
Bearing upon the Problem of
Infant Conservation, 134
Detroit
Babies' Milk Fund Assn., 391
Visiting Nurse Assn., 391
Diet Kitchen Assn., New York City,
403
of the Oranges, 399
District Nursing Assn., Providence,
417
District of Columbia, Baby Saving
Activities in, Reports of:
Department of Health, Arthur
L. Murray, M. D., 320
Instructive Visiting NurBe So-
ciety, Isabel Strong, 326
Woman's Clinic Auxiliary, Mrs.
John Hays Hammond, 328
Providence Hospital, 0. Lloyd
Magruder, M. D., 330
INDBX
441
Associated Charities, Miss Bell,
331
Baby /Hospital Camp, Louise
Taylor-Jones, M. D., 334
Woman's Welfare Department,
National Civic Federation,
Mrs. Archibald Hopkins, 335
Washington Diet Kitchen Asso-
ciation, Mary Gwynn, 337
Monday Evening Club, Chas. F.
Nesbit, 339
Central Milk Committee, W. J.
French, M. D., 339
Duluth Consistory Scottish Rite Ma-
sons Committee on Infant
Welfare, 393
Education of Parents in Practical
Eugenics
Mrs. John Hays Hammond, 135
Kvangeline Wilson Young, M.
D., 1GO
Discussion :
Johnson, Roswell H., 164, 167
Putnam, Mrs. Win. Lowell, 165
Hart, Hastings H., LL. D., 165,
167
Putnam, Helen C., M. D., 167
Wilbur, Cressy L., M. D,, 167
Elizabeth, N. J., Visiting Nurse
Assn., 397
Bmmons, A. B., 2nd,, M. D., Obstet-
ric Care of the Maverick Dis-
pensary, 227
English Speaking Conference on In-
fant Mortality, Report on,
Henry L. Coit, M. D., 55
Resolutions, etc., 21, 57
Etcaberger, M. Frances, Private
Duty Nurses and the Preven-
tion of Infant Mortality, 69
Eugenics, Education of Parents in
Practical, 135, 160, 164, 167
Eugenics, Session on, 133
Discussion, 133, 137, 138, 146,
104
Executive Secretary, Report of, 19
Exhibit, Travelling, 19
Financial Statement, 23
Flamiagan, Roy K., M. D., Discus-
sion, 138
Flies and Infant Mortality, 116
Ford, C. E., M. D., Department of
Health, 341
Foundling Asylum, The, and the Un-
married Mother, Ellen C. Bab-
bitt, 363
Foundlings, Earliest Provision for,
28
Washington Home for, 331
French, W. J., M. D., Central Milk
Committee, 339
Fulton, Gavin, M. D., Discussion, 204
General Session, Reports on Baby
Saving Activities in the Dis-
trict of Columbia, 320
Goler, George W., M. D., Midwifery
Report, 241
Goodwin, Mrs. E. R., Discussion, 79
Grand Rapids Charity Organization
Society, 392
Clinic for Infant Feeding, 392
Greene, Henry Copeley, Report of
Massachusetts Commission for
the Blind, 229
Gwynn, Mary, Washington Diet
Kitchen Association, 337
Hamilton, Ontario, Babies' Dispen-
sary Guild, 368
Hammond, Mrs. John Hays, Educa-
tion of Parents in Practical
Eugenics, 135
Woman's Clinic Auxiliary, 328
Hart, Hastings H., LL. D., Discus-
sion, 165, 167
Health Board of Richmond, 418
Health Bureau, Rochester, N. Y., 408
Health Department, Boston, 223
Health, State Board of, N. C., 411
Heat and Infant Mortality, Biblio-
graphy, 126
Heat and Infant Mortality, J. W.
Schereschewsky, M. D., 99
Discussion :
Gooley, T. B., M. D., 128, 131
Talbot, Fritz B., M. D., 129
Abt, I. A., M. D., 129
Shaw, H. L. K v M. D., 130
Schwarz, Herman, M. D., 130
Woodward, Wm. C., M. D., 131
442
INDEX
Levy, Julius, M. D., 131
Schereschewsky, J. W., M. D.,
132
Hebrew Infant Asylum, New York
City, 404
Helinholz, Henry F., M. D. ? Chair-
man, Session on Pediatrics, 85
Heredity, Tuberculosis and, 149
Holt, L. Einrnett, M. D, 5 Infant Mor-
tality, Ancient and Modern,
Address, 24
The Place of the Hospital, 359
Discussion, 89
Home Making, Continuation Schools
of, 251
Hopkins, Mrs. Archibald, Woman's
Welfare Department, National
Civic Federation, 335
Hospital Care, Maternity, for the
Woman of Moderate Means,
208
Housing and Infant Mortality (Sec
J. W. ScherescheivsTcy)
Houston, Texas, Settlement Assn.,
418
Hunt, Caroline L., Discussion, 280
Huntington, James Lincoln, M. D.,
Report on Obstetrics, 218
Hygiene, Teaching of, and the Pre-
vention of Infant Mortality,
I. A. Abt, M. D., 01
Discussion :
Knox, J. H. Mason, Jr., M. D.,
95
Putnam, Helen C., M. D., 96
Baker, S. Josephine, M. D., 96,
97
Marlatt, Abby L., 97
Clarke, T. Wood, M. D., 97
Leete, Harriet E., 98
Ideal Obstetric Out-Patient Clinic,
The, F. S. Newell, M. D., 191
Discussion :
Williams, J. Whitridge, M. D.,
200
Baker, S. Josephine, M. D., 203,
207
Fulton, Gavin, M. D., 204
Bennett, H. W., M. D., 205
Pinneo, F. W., M. I)., 206
Schwarz, Henry, M. D., 207
Illegitimate Infants, Care of:
Germany, 47
Leipzig, 47
Indianapolis Children's Aid Assn.,
373
Infant Aid Assn., Manchester, N. H.,
397
Infant Conservation, Results from
Experimental Breeding Bear-
ing upon the Problem of, 134
Infant Feeding, 86, 89, 90
Infant Feeding Conference, St.
Louis, 395
Infant Life, Sacrifice of, Among
Ancients, 26
Infant Mortality
and Baby-Saving Activities,
341, 365
and Factory Employment of
Women, 34
and Flies, 116
and Housing, 109, 111, 125
and Infant Feeding, 86, 89,
90
and Milk Depots, 44
and Milk Production, 37
and Stale or Germ-laden Milk,
112, 125, 128, 131, 132
and the Private Duty Nurse,
69
Bibli-ograpliy, 54
Conferences and Congresses on,
42, 55
Economic Aspects, 26, 43, 44
Education of Parents in Prac-
tical Eugenics a Factor In the
Prevention of, 135, 160
Effects of Urbanization of Pop-
ulation on, 34
Essentials in Campaign against,
52
Heat and, 99
in Europe, in the Middle of
the 19th Century, 35
In Institutions, 31
in the 17th and 18th Cen-
turies, 30
Methods Followed In the Redxic-
tion of, in New York City,
49
(See 'also reports of Affiliated
Societies, S67)
Nursing Problems In Rural
Communities, 75
INDEX
443
Prenatal Care, 174, 182, 184,
187, 378, 385 (See also Re-
ports of Affiliated Societies)
Teaching of Hygiene and its
Relation to, 91
Infant Mortality, Ancient and Mod-
ern: An Historical Sketch,
Address by the President, L.
Einmett Holt, M. D., 24
Infant Mortality Nursing Problems
in Rural Communities, Fan-
nie F. Clement, 75
Discussion :
Goodwin, Mrs. E. R., 79
Clement, Fannie F., 80, 81
Putnam, Mrs. Wm. Lowell, 81,
82, 83
Nevins, Georgia M., 81
Lent, M. E., 81, 82, 83
Clarke, T. Wood, M. D., 82
Ahrens, Minnie H., 83
Boyd, T. Hunter, 84
Infant Mortality, Prevention of,
Public School Education for,
251
Infant Welfare and the Commun-
ity, Mary Sherwood, M. D.,
283
Infant Welfare Associations:
(See Affiliated Societies)
Infant Welfare Committee, Syra-
cuse, 408
Infant Welfare Nurses, Standards
for, 02
Jacobs, Emma Suter, Discussion,
257, 269
Johnson, Roswell H., Discussion,
164, 167
Jordan, H. B. t Ph. D., Chairman,
Session oil Eugenics, 133
Discussion, 138
Kane, C. J. ? M, D. } Midwifery Re-
port, 242
Kerr, Anna W,, Discussion, 67
Knlpp, Gertrude B., Report of Ex-
ecutive Secretary, 19.
Knox, J, H. Mason, Jr., M. D,, The
Claim of the Baby, 289
The Dispensary, Social Service
Department, 361
Discussion, 95
Kober, George M., M. D., Acting
Chairman, Session on Vital
and Social Statistics, 293
Kosmak, George W., M. D., Mater-
nity Hospital Care for the
Woman of Moderate Means,
208
Midwifery Report, 237
La Forge, Zoe, Standards for In-
fant Welfare Nurses, 62
La Salle, Chancellor Memorial Milk
Station, 372
Lathrop, Julia C., Chairman, Ses-
sion on Vital and Social Sta-
tistics, 293
Leete, Harriet L., Chair man, Nurs-
ing and Social Work, 59, 67,
68, 72, 74
Discussion, 98
Legislation Concerning Employment
of Women in Factories, 41
Legislation for Protection of In-
fancy, 40
Lent, M. B., Discussion, 81, 82, 83
Levy, Julius, M. D,, Discussion, 89,
131
Midwifery Report, 244
Lichtenstein, Frances F., Report of
Committee on Nursing and
Social Work, 59
Lippitt, Louisa C., Discussion, 278
Louisville Babies' Milk Fund Assn.,
376
Lying-in Hospital and Dispensary,
Chicago, 372
McLanahan, Austin, Report of
Treasurer, 23
Magruder, G. Lloyd, M. D., Prov-
idence Hospital, 330
Manchester, N. H., Infant Aid As-
sociation, 397
Marlatt, Abby L,, Discussion and
Report, 97, 257, 282
Marshall, Harry T., M. t>., Tuber-
culosis and Heredity, 149
444
INDEX
Maryland Association for Study and
Prevention of Infant Mortal-
ity, 378
Massachusetts -
Babies' Hospital, 382
Commission for the Blind,
Work of, for the Prevention
of Ophthalmia Neonatorurn,
Henry Copley Greene, 229
Milk Consumers' Association,
383
Maternity Hospital Care for the
Woman of Moderate Means,
George W. Kosmak, M. D.,
208
Maternity Hospital, Place of, In the
Ideal Plan, J. Whitridge Wil-
liams, M. D., 355
Maverick Dispensary, Boston, 385
Membership, 22, 420
Metropolitan Life Insurance Co.,
Industrial Dept, New York
City,
Midwifery Reports:
Providence, E. I., 236
Utica, 238
New York City, 239
Syracuse, 240
Schenectady, 240
Rochester, 241
Paterson, N. J., 242
Orange, N. J., 242
Newark, N. J., 244
Washington, D. C. } 246
Virginia, West Virginia and
North Carolina, 246
Midwives, 174, 179, 180, 183, 202,
203, 204, 205, 206, 222, 229,
232-250
Midwives in New England:
Maine, 233
Vermont, 234
Manchester, 234 j
Boston, 235
Fall River, 236
Providence, 236
New Haven, 237
Milk and Baby Hygiene Assn., Bos-
ton, 387
Milk Committee, New York, 405
Milk Consumers' Association, Mas-
sachusetts, 383
Milk Depots:
(See Affiliated Societies)
England, 44, 46, 48
Milk, Effects of Stale or Germ-
laden, 112, 125, 128, 131, 132
Minneapolis Infant Welfare Society,
394
Murray, Arthur L., M. D., Depart-
ment of Health, 320
National Puericulture, Antonio Vi-
dal, M. D., 169
Nesbit, Charles F., Monday Even-
ing Club, 339
Nevins, Georgia M,, Discussion, 72,
73, 81
Newark, N. J., Babies' Hospital, 398
Newell, F. g., M. D., The Ideal Ob-
stetric Out-Patient Clinic, 191
New England Sub-Committee on
Obstetrics, 218
New Haven Infant Welfare Assn.,
370
New York Assu. for the Blind, 400
New York City :
Babies' Welfare Association, 51
351
Diet Kitchen Assn., 403
Division of Child Hygiene, 49
59, 239
Hebrew Infant Asylum, 404
Metropolitan Life Insurance Co.,
Industrial Dept.
Milk Committee, 50
Nichols, Henry J., M. 'D., The Re-
lation of Experimental Syph-
ilis to Eugenics, 130
Norris, John L., M, I)., Report on
Obstetrics, 240
North Carolina State Board of
Health, 411
Nurses' Training School, Battle
Creek, 390
Nursing and Social Work, Session
on, 59
Nutting, M. Adelaide, Discussion 66
07, 73, 74
Nutting, Adelaide M., r JtV Ideal
Visiting Nurse, 353
Obstetric Care of the Maverick Dis-
pensary, Boston, A. B. Em-
mon, 2nd, M. D,, 227
Obstetric Out-Patient Clinic, The
Ideal, 391
Obstetrical Education in the Medical
Schools, Status of, 218
Bowdoln t 218
445
Boston University, 219
Tufts College, 220
Harvard, 220
Yale, 221
Obstetrical Standards in Actual
Practice, 222
Obstetrics, Session on, 173
Ophthalmia Neonatorum, Work of
Massachusetts Commission for
the Blind, for Prevention of,
229
Orange, N. J,, Diet Kitchen, 399
Paquin, Paul, M. D., Discussion, 156
Pediatrics, Session on, 85
Pennsylvania, Children's Aid Society
of, 41G
Philadelphia, Child Federation of,
415
Children's Aid Society, 416
Pinneo, F. W., M. D., Discussion,
148, 200
Pisek, Godfrey R., M. D., Discussion,
89
Porter, Katherine, M. D., Midwifery
Report, 242
Potter, P. S., M. D., Midwifery Re-
port, 240
Prenatal and Postnatal Work, De-
partment of Health, Boston,
225
Prenatal Care, Henry Schwarz, M.
D., 174
Discussion :
Van Ingen, Philip, M. D., 1S2
West, Mrs. Max, 184
Putnam, Mrs. Win. Lowell, 187
(See also Reports of Affiliated
^octette*, 367)
Private Duty Nurses and the Pre-
vention of Infant Mortality,
M. Frances Etehberger, 69
Discussion :
Ahrens, Minnie H,, 71
Baker, S. Josephine, M. D., 71
Kevins, Georgia M., 72, 73
Nutting, M, Adelaide, 73, 74
Clement, Fannie F., 73
Welsh, Lilian, M. D., 73
Progress in Vital Statistics and
Birth Registration, Cressy L.
Wilbur, M. D,, 313
Providence District Nursing Assn.,
417
Public School Education for Pre-
vention of Infant Mortality,
251
Puericulture, National, 169
Putnam, Helen C., M. D., Chairman,
Session on Continuation
Schools of Home Making, 251
Discussion, 68, 96, 167
Putnam, Mrs. Wm. Lowell, Discus-
sion, 68, 81, 82, 83, 165, 187
Relation of Experimental Syphilis
to Eugenics, Bibliography,
146
Relation of Experimental Syphilis
to Eugenics, Discussion:
Cole, Leon, L, M. D., 146
Pinneo, F. W, M. D., 148
Relation of Experimental Syphilis
to Eugenics, The, Henry J.
Nichols, M. D., 139
Report of Committee on Nursing and
Social Work, F. F. Lichten-
stein, 59
Reports on Obstetrics:
New England Sub-Committee,
James Lincoln Huntington, M.
D., 218
New York and New Jersey Sub-
committee, George W. Kos-
mak, M. D., 237
Sub-Committee for the South-
Eastern States and the Dis-
trict of Columbia, John L.
Norris, M. D., 246
Resolutions adopted at Washington
Meeting, American Association
for Study and Prevention of
Infant Mortality, 17
Adopted by English-Speaking
Conference on Infant Mortal-
ity,, 57
Results from Experimental Breed-
ing Bearing upon the Problem
of Infant Conservation, Chas.
B. Davenport, Ph. D., 134
Discussion :
Flannagan, Roy K, M. D., 138
Jordan, H. E., Ph. D., 138
Richmond Board of Health, 418
Rochester, N. Y., Health Bureau,
408
Rural Communities, Infant Mortal-
ity Nursing Problems in, 75
446
INDEX
St. Louis Children's Hospital, 396
Infant Feeding Conference,
395
Scheresehewsky, J. W., M. D., Heat
and Infant Mortality, 99
Discussion, 132
Schwarz, Henry, M. D. ? Prenatal
Care, 174
Discussion, 207
Schwarz, Herman, M. D., Simple
Milk Dilution Feeding, 86
Discussion, 130
Schools for Midwlves, 170, 184, 204,
207, 239
Session on
Continuation Schools, 251
Eugenics, 133
Nursing and Social Work, 59
Obstetrics, 173
Pediatrics, 85
Vital and Social Statistics, 203
Local Activities, 320
Sunday, 283
Shaw, BO. L. K., M. D., 'Discussion,
130
Sherwood, Mary, M. D., Chairman,
Session on Obstetrics, 173
Infant Welfare and the Com-
munity, 283
Simple Milk Dilution Feeding, Her-
man Schwarz, M. D., 86
Discussion :
Pisek, Godfrey, R., M. D., 89
Holt, L. Bmmett, M. D., 89
Levy, Julius, M. D., 89
Helmholz, Henry F., M. D., 90
Trundle, A. S., 90
Society for Helping Destitute Moth-
ers and Infants, Boston, 389
South Bend Children's Dispensary
and Hospital Assn., 374
Standards for Infant Welfare
Nurses, Zoe La Forge (See
also F. F. Lichtenstein), 62
Discussion :
Nutting, M. Adelaide, G6, 67
Kerr, Anna W,, 67
Putnam, Helen C., M. D., 68
Putnam, Mrs. Win. Lowell, 68
Clement, Farinie F., 68
Stone, Ellen A., M. D., Midwifery
Report, 236
Strong, Isabel, Instructive Visiting
Nurse Society, Washington,
236
Sunday Session, 283
Syphilis, Experimental, Relation of,
to Eugenics, 139
Syracuse Infant Welfare Committee,
408
Talbot, Fritz B., M. D., Discussion,
129
Taylor-Jones, Louise, M. D,, Baby
Hospital Camp, 334
Teaching -of Hygiene and its Rela-
tion to the Prevention of In-
fant Mortality, I. A. Abt, M.
D., 91
Treasurer's Report, 23
True, A. C., Ph. D., Discussion, 278
Trundle, A. S., Discussion, 90
Tuberculosis and Heredity, Harry
T. Marshall, M. D., 149
Bibliography, 150, 151, 152, 153,
154, 156
Discussion, 15G
Use of Vital Statistics for Conserva-
tion of Infant Life, The, Wm.
C. Woodward, M. D., 294
Utica Baby Welfare Committee, 410
Van Der Bogert, Frank, M. D., Mid-
wifery Report, 240
Vandervort, Mrs., 257
Van Ingen, Philip M. D., 'Discus-
sion, 182, 310
Van Schaick, John, D, D., The Part
of the Church, 365
Van Trump, Miss, Discussion, 316
Vidal, Antonio, M.D., National Puer-
iculture, 169, Discussion, 315
Visiting Nurse Association:
Cincinnati, 413
Cleveland, 413
Detroit, 391
Elizabeth, N. J., 397
Providence, 417
INDEX
447
Vital Statistics:
Beginning of, 30
Session on, 293
Use of, f'or Conserving Infant
Life, 294
and Birth Registration, 313
Vital and Social Statistics, Discus-
sion:
Putnam, Helen C., M. D., 303
Woodward, W. C., M. D., 303,
317, 318
Baker, S. Josephine, M. D., 304,
311
Holt, L. Emmett, M. D., 307
Fulton, John S., M. D., 308
Ford, C. B., M. 'D., 310
Van Ingen, Philip, M. D., 310
Meriam, Lewis, 311
Putnam, Mrs. Wm. Lowell, 312
Vidal, Antonio, M. D., 315
Van Trump, Miss, 316
Welsh, Lilian, M. D., 73
West, Mrs. Max, Discussion, 184
Wilbur, Cressy L., M. D., Progress
in Vital Statistics and Birth
Registration, 313
Discussion, 167
Williams, J. Whitridge, M. D., The
Place of the Maternity Hos-
pital, 355
Discussion, 200
Woodward, Wm. C., Use of Vital
Statistics for the Conserva-
tion of Infant Life, 294
Address, 286
Discussion, 131, 217, 318
Young, Evangeline Wilson, M. D.,
Education of Parents in Prac-
tical Eugenics, 160
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